Get Special Transportation - Certification Of Need Form - Medica

Filling out the Special Transportation - Certification Of Need Form - Medica is a crucial step for users needing assistance with transportation to medical appointments. This guide provides a step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Special Transportation form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the today's date at the top of the form. This is essential for processing timelines.
3. In the 'Medica Member Information' section, fill in the Group Number and ID Number accurately. This information helps in verifying your membership.
4. Provide the Medica member's name and date of birth. Make sure the name matches the records held by Medica.
5. Indicate whether the member requires transportation with assistance by checking either 'Yes' or 'No'. If 'Yes', select the appropriate option for transportation type: Wheelchair, Ambulatory with Assistance, or Stretcher.
6. If applicable, specify if there is a permanent impairment or disability by checking 'Yes' or 'No'. If 'No', provide the expected duration of impairment or disability.
7. Enter the authorizing provider’s details, including specialty, Medica ID number or NPI, and their name. This is important for validation and approval.
8. Fill in the diagnosis codes in the designated section. This helps in understanding the medical necessity for transportation.
9. In the impairment section, describe the physical or mental impairment that necessitates special transportation.
10. The authorizing provider must sign and date the form certifying that they have reviewed the member's medical history and that the criteria have been met.
11. Complete the special transportation provider information, including provider ID number, name, contact number, and address.
12. Indicate the anticipated first ride date and the end date, noting that it expires one year from the first ride date.
13. Review the form for any incomplete or illegible sections. Ensure that all required fields are filled out correctly.
14. Once completed, save your changes. You can download, print, or share the form as necessary.

Complete your Special Transportation - Certification Of Need Form - Medica online to ensure timely approval for transportation assistance.