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COCC Form

This document outlines an agreement for continuity of care between primary care physicians, specialists, and admitting physicians/practices. It allows primary care physicians and specialists to satisfy network credentialing requirements by establishing arrangements with participating acute care physicians/practices to admit their patients requiring hospitalization. The admitting physicians must have the same specialty, participate in the same networks, and have admitting privileges at an acute care hospital in the network. The document provides sections for applicant and admitting practitioner information and requires both parties to ensure communication and coordination of care during and after any hospital admission.

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Aurangzeb Jadoon
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47 views2 pages

COCC Form

This document outlines an agreement for continuity of care between primary care physicians, specialists, and admitting physicians/practices. It allows primary care physicians and specialists to satisfy network credentialing requirements by establishing arrangements with participating acute care physicians/practices to admit their patients requiring hospitalization. The admitting physicians must have the same specialty, participate in the same networks, and have admitting privileges at an acute care hospital in the network. The document provides sections for applicant and admitting practitioner information and requires both parties to ensure communication and coordination of care during and after any hospital admission.

Uploaded by

Aurangzeb Jadoon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CONTINUITY OF CARE COVERAGE AGREEMENT

Primary care physicians (i.e., family practitioners, pediatricians and internal medicine) and specialists who choose to limit
their practice to providing services in their offices may satisfy the requirement to maintain hospital admitting privileges
within our Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
administrative policy by establishing an arrangement with another participating acute care physician or physician group
practice to care for the applicant’s patients who require acute care at a network hospital.

The admitting physicians/group practices must have the sam e or a similar specialty, must participate in the sam e
network(s), and must have admitting privileges at an acute care hospital that participates in the appropriate Horizon
network(s) for patients being treated.

FORM SUBMISSION
Submit this form, along with other credentialing documentation, through our online Enrollment Tool (which can be
accessed through the Join Our Networks webpage), or mail it to:
Horizon BCBSNJ Credentialing & Recredentialing Department
3 Penn Plaza East, PP-14C
Newark NJ 07105-2200

APPLICANT INFORMATION
I, the applicant, in accordance with our Credentialing and Recredentialing Policy for Participating Physicians and
Healthcare Professionals, have arranged for patients requiring hospitalization to be admitted under the care of the
physicians/physician group practices noted below at the network hospital or BlueCard® hospital noted below.

To ensure continuity of care, I, the applicant, working with the admitting physician(s)/physicians’ group(s) noted below will:
• Provide all relevant current and past medical history and pertinent records,
• Obtain notification of discharge and a copy of the hospital discharge summary,
• Make arrangements for a follow-up appointment within an appropriate time frame.

Applicant Name Ｇａｅｔａｎ Ｍｏｉｓｅ


Applicant Type 1 NPI １２５５５８０８５８
Date of Applicant Signature ０１／０１／２０２４
Applicant Signature

ADMITTING PHYSICIAN/PRACTICE INFORMATION


I/we, the admitting physician(s)/physicians’ group(s) agree to the above arrangement. To ensure continuity of care, I/we
will provide the applicant noted above with:
• All medical notes and pertinent hospital records,
• Notification of discharge and a copy of the hospital discharge summary.

Practitioner 1 Name Ａｕｒａｎｇｚｅｂ Ｊａｄｏｏｎ


Practitioner 1 Type 1 NPI ８７３８４７８３７８
Practitioner 1 Specialty Ｃａｒｄｉｏｌｏｇｙ
Group Practice 1 Name Ｓｈｉｆｉｑｕｅ Ｍｅｄｉｃａｌ Ｃｅｎｔｅｒ

5005-06202023

Products are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon NJ Health and/or Braven Health. Each company
is an independent licensee of the Blue Cross® Blue Shield® Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in
its capacity as administrator of programs and provider relations for all its companies. ©2023 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza
East, Newark, New Jersey 07105-2200.
Group Practice 1 Type 2 NPI ７８３７４８３７８２
Network/BlueCard® Hospital Name(s) Ａｙｕｂ Ｍｅｄｉｃａｌ Ｃｏｍｐｌｅｘ
Date of Practitioner 1 Signature ０１／０１／２０２４
Practitioner 1 Signature

Practitioner 2 Name Ｈａｍｍａｄ Ｐｅｒｖａｉｚ


Practitioner 2 Type 1 NPI ８３７８２７８１７８
Practitioner 2 Specialty Ｐｅｄｉａｔｒｉｃｓ
Group Practice 2 Name Ｓｈａｆｉｑｕｅ Ｍｅｄｉｃａｌ Ｃｅｎｔｅｒ
Group Practice 2 Type 2 NPI ７８３７４８３７８２
Network/BlueCard® Hospital Name(s) Ｊｉｎｎａｈ Ｈｏｓｐｉｔａｌ
Date of Practitioner 2 Signature ０１／０１／２０２４
Practitioner 2 Signature

Practitioner 3 Name Ｕｚａｉｒ Ｑｕｒｅｓｈｉ


Practitioner 3 Type 1 NPI ９８７６５４３４５６
Practitioner 3 Specialty Ｐｕｌｍｏｎｏｌｏｇｉｓｔ
Group Practice 3 Name Ｓｈａｆｉｑｕｅ Ｍｅｄｉｃａｌ Ｃｅｎｔｅｒ
Group Practice 3 Type 2 NPI ７８３７４８３７８２
Network/BlueCard® Hospital Name(s) Ｓｈａｈｅｅｎａ Ｊａｍｉｌ Ｈｏｓｐｉｔａｌ
Date of Practitioner 3 Signature ０１／０１／２０２４
Practitioner 3 Signature

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