Transition of Care Request Form

Transition of Care Form

1. Member First Name *This question is required.

2. Member Last Name *This question is required.

3. Member Phone *This question is required.

4. Priority Health ID Number *This question is required. Tip: Your Priority Health ID # can be found on your member ID card

5. Are you a new Priority Health member within the past 90 days? *This question is required.Please note: Transition of Care authorizations are only available within the first 90 days of eligibility with Priority Health Medicaid.

If a person other than the member is completing this form, please enter your information below.

6. Name

7. Phone

8. Fax

9. Relationship to member