Transition of Care Form - Anthem 2026

1. Click ‘Get Form’ to open the Transition of Care Form in the editor.
2. Begin by filling out the Subscriber/Employer Info section. Enter the Subscriber Name, Coverage Effective Date, Group Number, Employer Name, and Type of Coverage (HMO or PPO).
3. Next, complete the Patient Info section. Provide the Patient Name, Date of Birth, Patient ID#, Home and Work Telephone Numbers, Address, and the Best Time to Contact.
4. In the Provider Info section, list your Primary Care Provider's name, address, and telephone number. If applicable, include details for up to two specialists.
5. Indicate the Services Requested for Transitional Care by checking all relevant boxes. Be sure to specify any additional details in the provided fields.
6. Describe briefly any active treatment being received and answer whether you are working with a nurse case manager. Indicate if you would like to be contacted by Case Management.
7. Finally, sign and date the form at the bottom before submitting it via mail or fax as indicated.

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