Get Logisticare Transportation Delaware

Medical Necessity Form Delaware Non-Emergency Transportation Services Facility Department Telephone 866-469-2824 Fax 877-813-5599 In an effort to insure every member is transported by the most appropriate means necessary LogistiCare requires completion of this form for all wheelchair and stretcher transport requests. Please complete this form as accurately as possible and fax to the number shown above. The form will be kept on file for 6 months. The form can be completed by any Physician Physician Assistant Nurse Practitioner or Registered Nurse who has provided direct care for the client. Member Name Date of Birth Member s Medicaid Does Member require a Wheelchair. Yes No Is Member able to transfer stand and pivot. Must meet all 3 criteria to qualify for stretcher transport Can Member self-administer his or her own O2. Will the Member have an escort. Mode of Transportation Required Ambulatory Member uses wheelchair but is able to transfer safely in and out of a vehicle Wheelchair Van Member uses wheelchair and unable to safely transfer in/out of a vehicle Van Stretcher Member unable to sit but does not require any type medical monitoring Stretcher Member unable to sit and requires some type of medical monitoring If requesting wheelchair van van stretcher or stretcher please provide the qualifying ICD9 or Diagnosis Comments Signature Printed Name Title Facility Name Date I certify that the above information is true and correct based on my evaluation of this patient and represent that due to the member s condition he or she requires transport by the mode requested on this form* I understand that this information will be used by LogistiCare Utilization Review Department 5/7/15 and the Department of Medicaid and Medical Assistance DMMA to support the determination of medical necessity for services provided and that I have personal knowledge of the patient s condition at the time of transport. Please complete this form as accurately as possible and fax to the number shown above. The form will be kept on file for 6 months. The form can be completed by any Physician Physician Assistant Nurse Practitioner or Registered Nurse who has provided direct care for the client. The form can be completed by any Physician Physician Assistant Nurse Practitioner or Registered Nurse who has provided direct care for the client. Member Name Date of Birth Member s Medicaid Does Member require a Wheelchair. Yes No Is Member able to transfer stand and pivot. Member Name Date of Birth Member s Medicaid Does Member require a Wheelchair. Yes No Is Member able to transfer stand and pivot. Must meet all 3 criteria to qualify for stretcher transport Can Member self-administer his or her own O2. Must meet all 3 criteria to qualify for stretcher transport Can Member self-administer his or her own O2. Will the Member have an escort. Mode of Transportation Required Ambulatory Member uses wheelchair but is able to transfer safely in and out of a vehicle Wheelchair Van Member uses wheelchair and unable to safely transfer in/out of a vehicle Van Stretcher Member unable to sit but does not require any type medical monitoring Stretcher Member unable to sit and requires some type of medical monitoring If requesting wheelchair van van stretcher or stretcher please provide the qualifying ICD9 or Diagnosis Comments Signature Printed Name Title Facility Name Date I certify that the above information is true and correct based on my evaluation of this patient and represent that due to the member s condition he or she requires transport by the mode requested on this form* I understand that this information will be used by LogistiCare Utilization Review Department 5/7/15 and the Department of Medicaid and Medical Assistance DMMA to support the determination of medical necessity for services provided and that I have personal knowledge of the patient s condition at the time of transport.