Transition of care form: Fill out & sign online

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01. Edit your transition of care form online

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Click ‘Get Form’ to open the transition of care form in the editor.
Begin by entering the Patient Name and Date of Birth in the designated fields. This information is crucial for identifying the patient.
Next, fill in the Employee Name and Employee ID. This helps link the patient to their insurance coverage.
Indicate the Approval for section by specifying what services you are seeking approval for, followed by entering the Provider Name (Last, First) and their Address.
If known, provide the Tax Identification Number of the provider. This may expedite processing.
Fill out the Patient Diagnosis/ICD9 code to specify the medical condition requiring transition level benefits.
Specify Dates of Service by entering the start and end dates for which you are requesting coverage.
Review all entered information for accuracy before submitting. Once completed, you can fax or mail it directly to UMR as instructed.

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