Continuity of Care Request Letter PDF

Request temporary coverage to keep your current provider during transitions, with a signature-ready letter layout.

Continuity of care details

Keep your current provider covered while transitions complete. All fields are optional.

Status message placeholder

Policyholder Name

Address

Insurance Company

Policy Number

Member ID

Patient Name

Treating Provider Name

Provider Specialty

Condition / Treatment Summary

Why Disruption Would Harm Care

Requested DurationRequested Resolution

Generates a signature-ready continuity of care letter.

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Review details before sending; nothing here is legal advice or a substitute for local forms.