Unified School District 417

Continuation of Care Form

USD 417 Members – please complete the form below and include as much information as possible about the procedure or service you had authorized before moving to your Lucent Health plan. Lucent Health’s Concierge Care team will locate your member information and connect with you to resolve your concern as soon as possible.

Subscriber/Member Information

Condition/Diagnosis Information

Are you/the patient pregnant? If so, is the pregnancy high risk? *
Is the request related to infusion or injection therapy? *
Is there an active acute condition being treated? *
Is there a surgery or procedure scheduled? *
Are/were you or the patient hospitalized within 30 days of your enrollment? *
Is there an active course of chemotherapy or radiation? *
Is there active treatment from a recent (within 30 days) surgery? *
Are you/the patient receiving dialysis? *
Are you/the patient a candidate for organ transplant? *
Is any hospitalization expected in the next 90 days? *

Please complete the following information related to the provider from whom you've been receiving care:

Click or drag a file to this area to upload.

I hereby authorize the above health care provider to give Lucent Health, and any affiliates and contracted parties, any and all information and medical records necessary to make an informed decision concerning my request for Transition of Care/Continuity of Care. I understand I am entitled to a copy of this authorization request form. I also authorize Lucent Health Concierge Care to leave confidential information in my email or on my voice mail at the following number(s) listed above.

Please check all that apply: *

Questions? Members can also contact Lucent Health Concierge Care by calling (888) 585-3309. Concierge Care is available Monday-Friday from 7am-7pm CST.