Amended Form 02CB010E- Member Provider Change/Transfer of ADvantage Members, and HIPAA Compliance
A revised Change of Provider Form 02CB010E (ADv10) has been posted to and is available on the ADvantage Forms Directory page, (updated on 08/15/2016). This amended form guides the appropriate transfer process. In addition to promoting collaboration of service providers based on ADvantage Case Management and Program Service Standards, the form is compliant with the Health Insurance Portability and Accountability Act (HIPAA).
When a Member requests a change in Provider, the current Case Manager is always responsible for presenting the 02CB010E (ADv10) to their current Member for signature, consenting to the Member's choice of new Provider. The current Case Manager is always responsible for signing page one of the 02CB010E (ADv10). In addition the current Case Manager is responsible for providing case management services to the Member until the transfer has been completed. To ensure continuity of service delivery to the Member throughout the transfer process, the current case manager is also responsible for finalizing the completed Member Provider Change Form by signing and dating the bottom of page 2 of the 02CB010E (ADv10) when the transfer has been completed.
We are attaching the amended version of the ADvantage Program Member Change of Provider form 02CB010E (ADv10), and instructions for immediate use by all Providers. Please carefully review the attached amended documents for the detailed procedure, and destroy all previous versions of this form.
This amended 02CB010E (ADv10) form will be required with all transfer addendums beginning April 1st, 2017.
In the event your agency is out of compliance with use of the new form on or after April 1, or required information is missing and/or is incomplete, the Case Management line of service will be conditioned, and the transfer will not be processed until the issue(s) is (are) corrected.
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