This file combines the Blue Cross cover sheet with the Mass Collaborative form.
For our members who are in active treatment with a provider who leaves our network, they may be eligible to receive coverage for up to 90 days. Use this form to submit a continuity of care request within 90 days of their continued care needs.
Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.
Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.
This file combines the Blue Cross cover sheet with the Mass Collaborative form.
This file combines the Blue Cross cover sheet with the Mass Collaborative form.
Please file this form one week prior to the last covered service. For more instructions on how to complete the form, refer to our Guide.
