Get Nea Alaska Non-emergency Medical Travel Request Form - Ebms

Filling out the NEA Alaska Non-Emergency Medical Travel Request Form - EBMS online is a straightforward process designed to ensure the smooth processing of travel requests for medical purposes. This guide provides a step-by-step approach to help you complete the form accurately and efficiently.

Follow the steps to complete your travel request form.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin by providing the general information sections. Enter the patient's name and the member's name, indicating if the patient is an underage child. Fill in the member's ID number as well.
3. Next, fill out the travel details. Specify the number of passengers, date of departure, date of service, and date of return. Indicate whether the ticket has been purchased by marking 'Yes' or 'No,' and enter the ticket cost, travel agent service fee, and total ticket price.
4. If the ticket was purchased less than two weeks prior to travel, provide an explanation in the designated section.
5. If the patient is a minor, identify the parent or legal guardian and the date the ticket was purchased.
6. Describe the purpose of the trip clearly. This may include specifying the medical treatment or services being sought.
7. The referring physician must complete the next section. They should detail the condition being treated, indicate if the treatment was due to an accident or medical emergency, and confirm whether the treatment or surgery can be performed locally.
8. Obtain the physician's signature along with their phone number and the date for the completion of the medical section.
9. The member must sign and date the form to verify the information provided.
10. Once all sections are completed, ensure the form is saved. You can then download, print, or share the completed form as needed.

Start completing your NEA Alaska Non-Emergency Medical Travel Request Form - EBMS online now to ensure you meet the necessary deadlines.