[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283917-105":53,"doc-detail-283917-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","continuity-of-care-form-complete-and-submit-request","Continuity of Care Form - Complete and Submit Request","","Continuity of Care Form instructions guide members and care providers through completing patient, authorization, and signature sections and submitting the request for continued coverage at in-network benefit levels. The form requires clear entry of patient details, treatment condition information, provider or facility termination data, diagnoses using ICD10, and treatment duration expectations. Requests are reviewed and followed by an approval, denial, or incomplete determination letter, and completion does not guarantee approval.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/continuity-of-care-form-complete-and-submit-request/283917/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/continuity-of-care-form-complete-and-submit-request/283917.png","ImageObject",442,249,{"name":88,"@type":89},"Evangeline","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who must sign the Continuity of Care form, and what if the member is a minor?","Question",{"text":109,"@type":110},"The completed form must be signed by the member for whom Continuity of Care is requested. If the patient is a minor, a guardian’s signature is required.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should the completed form be submitted?",{"text":114,"@type":110},"The completed form can be returned by mail, fax, or submitted online. Online submission involves signing in at umr.com, selecting Contact us, choosing “Submit Continuity of Care form,” uploading the signed form, and selecting Submit.",{"name":116,"@type":107,"acceptedAnswer":117},"What happens after the request is received, and does completing the form guarantee approval?",{"text":118,"@type":110},"The request is reviewed and evaluated, and a letter is sent indicating approval, denial, or that the form is incomplete with no determination. Completion of the form does not guarantee that a Continuity of Care request will be granted.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283917,1791234936,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},13056703019662,"https://ap-avatar.wpscdn.com/avatar/be000253a8e92610077?_k=1778726343310543188","Continuity of Care Form  \nTo complete this form:  \n• Save and download the form to your device.  \n• Please make sure all fields are completed. Once completed, it must be signed by the member for whom the Continuity of Care is being requested. If the patient is a minor, a guardian’s signature is required. Use auto-signature to sign it electronically and save the completed form to your device.  \n• You are encouraged to apply for Continuity of Care within 30 days of the care provider’s termination date, as noted in the letter you received.  \n• A separate Continuity of Care form must be completed for each condition you and/or your dependents are seeking Continuity of Care.  \nSubmitting your form:  \nEither you or your provider can return the completed form along with relevant medical records and information by mail, fax or submitting online. Whether you or your provider submits the completed form, we encourage you to obtain a copy of the completed form for your records.  \nBy mail: UMR Continuity of Care, PO Box 8042, Wausau, WI 54402-8042  \nBy fax: 855-229-4454  \nTo submit online:  \n1. Sign in to [umr.com](umr.com) or create your account.  \n2. Select Contact us at the top of the screen.  \n3. In the Message center window, fill out required information.  \n4. In the Subject line drop-down, select Submit Continuity of Care form.  \n5. Upload your signed Continuity of Care form.  \n6. Select Submit.  \nNote: After receiving your request, we will review and evaluate the information provided. Once determination has been made, we will send you a letter to let you know if your request was approved, denied, or if the form is incomplete and no determination can be made. Completion of this form does not guarantee that a Continuity of Care request will be granted.  \n\n| Patient Information-Please print clearly. |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Full Name of Person Being Treated |  | Member ID Number\u003Cbr>(Refer to insurance ID card) |  | Date of Birth (mm/dd/yyyy) |\n| Address |  | City |  | State/ZIP Code |\n| Home/Cell Phone Number |  |  | Work Phone Number |  |\n| Employer Name | Group ID\u003Cbr>(Refer to insurance ID card) |  | Patient’s Relationship to Employee\u003Cbr>☐Self ☐Spouse\u003Cbr>☐Dependent ☐Other |  |\n| Authorization to release records:\u003Cbr>I authorize all physicians and other health care professionals or facilities to provide information concerning medical care, advice, treatment or supplies for the patient named above. This information will be used to determine the member’s eligibility for Continuity of Care benefits under the plan. |  |  |  |  |\n| Patient Signature/Parent or Guardian’s Signature if Member is a Minor |  |  |  | Date (mm/dd/yyyy) |\n\n@2024 United Healthcare Services, Inc. UMF0005 0124 UA 1  \n\n| Care Provider Section: Your terming physician should complete the following information. Please print clearly. |  |  |  |\n| --- | --- | --- | --- |\n| Provider Full Name | Provider Term Date | Termed Provider Tax ID Number (TIN) | Provider Office Phone Number |\n| Address |  | City | State/ZIP Code |\n| Hospital |  |  | Hospital Phone Number |\n| Primary Diagnosis (ICD10) |  | Secondary Diagnoses (ICD10) | Expected Length of Treatment\u003Cbr>(Up to 90 days from provider termination) |\n| Date of Last Visit (mm/dd/yyyy) |  | Next Scheduled Appointment (mm/dd/yyyy) | If Maternity: Expected Date of Delivery (mm/dd/yyyy) |\n| Please select 1 of the descriptions if it applies:\u003Cbr>☐Life-Threatening Condition ☐Acute Condition ☐Transplant ☐Inpatient/Confined\u003Cbr>☐Upcoming Surgery ☐Disabled/Disability ☐Terminal Illness ☐Ongoing Treatment |  |  |  |\n| Current and Associated Treatment(s)/Comments (Include all relevant CPT codes) |  |  |  |\n| We understand you are not, or soon will not be, a participating provider in our network. Our member is receiving treatment for the above medical condition from you and is seeking continued coverage at the network benefit level. If the member is eligible, you agree to (1) provide the covered service, including any f","cbCaiaMOrvNMTcg4","https://ap.wps.com/l/cbCaiaMOrvNMTcg4","pdf",215171,"English","# Instructions to complete the form\n## Submitting the request\n# Patient information\n## Authorization to release records\n# Care provider section\n## Diagnoses and treatment details\n# Care facility section\n## Diagnoses and treatment details","[{\"question\":\"Who must sign the Continuity of Care form, and what if the member is a minor?\",\"answer\":\"The completed form must be signed by the member for whom Continuity of Care is requested. If the patient is a minor, a guardian’s signature is required.\"},{\"question\":\"How should the completed form be submitted?\",\"answer\":\"The completed form can be returned by mail, fax, or submitted online. Online submission involves signing in at umr.com, selecting Contact us, choosing “Submit Continuity of Care form,” uploading the signed form, and selecting Submit.\"},{\"question\":\"What happens after the request is received, and does completing the form guarantee approval?\",\"answer\":\"The request is reviewed and evaluated, and a letter is sent indicating approval, denial, or that the form is incomplete with no determination. Completion of the form does not guarantee that a Continuity of Care request will be granted.\"}]","Continuity of Care Form - Complete and Submit Request | PDF",1789622449]