US Global Administrators

Transition of Care Form

US Global Administrators Members – please complete the form below and include as much information as possible about the procedure or service you had authorized before moving to US Global Administrators. The US Global Administrators Concierge Care team will locate your member information and connect with you to resolve your concern as soon as possible.

Type of Terminating Plan
Do you have an upcoming appointment to see a specialist?
Enter your provider information below. Note that you must complete this form once for each diagnosis/provider.
Are you currently receiving any of the following services?
Service
Do you have any hospitalizations, surgeries or procedures scheduled?
Have you been admitted to the hospital or seen in the emergency room in the past 6 months?
Click or drag a file to this area to upload.
I hereby authorize the above provider to give the US Global Administrators Concierge Care team any and all information and medical records necessary to make an informed decision concerning my request for Transition of Care. I understand that Lucent Health and US Global Administrators may share information and discuss my care with my new Primary Care Physician/Medical Group under my US Global Administrators health plan. I understand that I am entitled to a copy of this authorization form. I also authorize US Global Administrators to leave confidential information on my voice mail at the following number(s) listed above. Please check all that apply:

Any questions? Members can also contact US Global Administrators Concierge Care by calling 1 (844) 819-4456.