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Get Attachment - Form 216 - Scdhhs.gov - Scdhhs
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How to fill out the Attachment - Form 216 - SCDHHS.gov - Scdhhs online
Filling out the Attachment - Form 216 - SCDHHS.gov is an essential process for securing medically necessary ambulance transportation under Medicaid. This guide provides clear, step-by-step instructions to help you accurately complete the form and ensure compliance with necessary protocols.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to obtain the Attachment - Form 216. This will allow you to access the form in your preferred online editor.
- Enter the beneficiary’s name and Medicaid I.D. number in the designated fields.
- In the certification section, indicate that it is medically necessary for the patient to be transported by ambulance. Make sure to check that the patient is unable to ambulate without assistance.
- Select the level of ambulance transport required from the provided options, specifically noting if Basic Life Support is needed.
- Indicate the Medicaid service destination by selecting from the available options, such as residence, physician office, hospital, or nursing home.
- If applicable, detail the existing medical condition that justifies the need for transport in the specified section.
- Fill in the vehicle odometer readings for both ‘To’ and ‘From’ sections to record the distance of the transportation.
- Complete the requestor's name and title along with the facility name to finalize the form.
- Review all entries for accuracy and completeness before saving, downloading, printing, or sharing the form.
Complete your documents online today to ensure timely processing.
Adults: Only medically necessary exams are covered for adults. Retroactive services and routine eye exams are not covered. Children: One eye exam and glasses are covered for children. Copayments A copayment is a fixed amount you pay for a covered health care service, usually paid at the time you receive the service.
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