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Use the form to request assistance coordinating care under the new medical plan and to request medical records from current providers. Transitional Care Benefits may be available up to 90 days after the group’s effective coverage date, with written requests reviewed after 90 days. Includes patient, medical, and physician information, authorization to Blue Cross and Blue Shield of Texas, and instructions for returning the form by fax or mail.",{"@graph":63,"@context":118},[64,80,101],{"@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/member-request-for-transitional-care-benefits-and-release-of-information/288882/",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/member-request-for-transitional-care-benefits-and-release-of-information/288882.png","ImageObject",442,249,{"name":88,"@type":89},"Aurora","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete this form?","Question",{"text":108,"@type":109},"Complete this form if you are currently receiving medical care from physician(s) not listed in your provider directory and want help coordinating that care with the new medical plan.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How long are Transitional Care Benefits available?",{"text":113,"@type":109},"For covered services, Transitional Care Benefits may be available for up to 90 days after your group’s effective date of coverage. After 90 days, requests made in writing are reviewed through the standard prior authorization process.",{"name":115,"@type":106,"acceptedAnswer":116},"What information does the authorization allow Blue Cross and Blue Shield of Texas to obtain?",{"text":117,"@type":109},"The authorization permits the Blue Cross and Blue Shield of Texas Medical Director (or designee) to obtain information and medical records from the listed physician(s)/provider(s) to make an informed decision about the transitional care benefits request.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288882,1791056059,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},4810365810221,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Member Request for Transitional Care Benefits and Release of Information  \nPlease complete this form if you are currently receiving medical care from physician(s) that are not listed in your provider directory and would like assistance in coordinating your medical care with the new medical plan. It may be necessary to request medical information from your current physician(s) . Transitional Care Benefits, for covered services, may be available for up to 90 days after your Group’s effective date of coverage. After 90 days, the Medical Director will review any requests for benefits, made in writing, according to our standard prior authorization review process.  \nImportant 􀀩 Transitional Care Benefits must be discussed with a Case Management Specialist if your group contract is already in effect. Please call the Pre-certification telephone number indicated on the back of your Identification Card. Providers not in the network of your plan may still bill for charges over our allowed amount.  \nGroup Name:   Group Number:    \nEmployee Name:   ID\\# / SS\\#   Date of Birth:    \nPATIENT INFORMATION  \nRelationship  \nName:   Date of Birth:   to Employee:    \nAddress:   City:   State:   ZIP:    \nPhone: Home:   Work:   Cell:    \nMEDICAL INFORMATION  \nWhat is the Health Condition, Diagnosis or Treatment   Plan for which the Patient is seeking Transitional  \nBenefits?    \nIs the Patient receiving care for a Pregnancy? Yes No If Yes, what is the estimated due date?    \nIs there a Surgery scheduled or recently done? Yes No If Yes, what is/was the date of the surgery?    \nIs the Patient currently on a Transplant list? Yes No If Yes, please provide a copy of the approval letter.  \nDoes Patient have a Physician appointment Yes No If Yes, please indicate the date of the  \nscheduled? Patient’s next appointment.    \nPHYSICIAN INFORMATION  \nPhysician Name Address Phone \\#  \n\n|  | Name of Facility (Hospital, DME, group) |  | Date of Last Visit | Date of Next Visit |\n| --- | --- | --- | --- | --- |\n| Physician Name |  | Address |  | Phone \\# |\n|  | Name of Facility (Hospital, DME, group) |  | Date of Last Visit | Date of Next Visit |\n\nPhysician Name Address Phone \\#  \n\n| Name of Facility (Hospital, DME, group) | Date of Last Visit | Date of Next Visit |\n| --- | --- | --- |\n\nA Utilization Management representative may contact you to obtain medical records for clinical review.  \nWhat is the best number to reach you? Home:   Work:    \nI hereby authorize the Blue Cross and Blue Shield of Texas Medical Director or designee to obtain any information and medical records  \nfrom the above physician(s) / provider(s) in connection with making an informed decision regarding my request for Treatment in Progress (Transitional Care benefits) under the Medical Health Plan. I understand that I am entitled to a copy of this Authorization Form.  \nSigned: (Patient or Guardian)  \nDate:  \n\n| Return form to: | Fax: 1-866-739-4093 | Mail: Blue Cross and Blue Shield of Texas\u003Cbr>Utilization Management – Transitional Benefits\u003Cbr>P.O. Box 833874\u003Cbr>Richardson, TX 75083-3874 |\n| --- | --- | --- |\n\nA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association","cbCainrGdI1kbiV0","https://ap.wps.com/l/cbCainrGdI1kbiV0","pdf",69049,"English","# Member Request Instructions\n# Patient Information\n# Medical Information\n# Physician Information\n# Authorization and Return Instructions","[{\"question\":\"Who should complete this form?\",\"answer\":\"Complete this form if you are currently receiving medical care from physician(s) not listed in your provider directory and want help coordinating that care with the new medical plan.\"},{\"question\":\"How long are Transitional Care Benefits available?\",\"answer\":\"For covered services, Transitional Care Benefits may be available for up to 90 days after your group’s effective date of coverage. After 90 days, requests made in writing are reviewed through the standard prior authorization process.\"},{\"question\":\"What information does the authorization allow Blue Cross and Blue Shield of Texas to obtain?\",\"answer\":\"The authorization permits the Blue Cross and Blue Shield of Texas Medical Director (or designee) to obtain information and medical records from the listed physician(s)/provider(s) to make an informed decision about the transitional care benefits request.\"}]","Member Request for Transitional Care Benefits and Release of Information | PDF",1789634151]