Get Ohio Jfs Ambulette Form

Filling out the Ohio Jfs Ambulette Form online can streamline the process of obtaining necessary medical transportation. This guide provides a step-by-step approach to ensure accurate and complete submission of the form.

Follow the steps to successfully complete the Ohio Jfs Ambulette Form.

1. Click the ‘Get Form’ button to access the Ohio Jfs Ambulette Form and open it for filling out.
2. Enter the patient's name in the designated field at the top of the form.
3. Fill in the patient's address, ensuring the details are correct and reflect their current residence.
4. Input the patient's Medicaid billing number as shown on their Ohio Medicaid Card.
5. Provide the name of the Ambulette Medicaid provider; this should be the service provider responsible for the patient’s transport.
6. Specify the Ambulette Medicaid provider's number, which is a seven-digit identifier unique to the provider.
7. Indicate the date(s) of the first transport by entering either a specific date or a range of dates, as applicable.
8. In section seven, check all applicable criteria that confirm why the patient requires an Ambulette instead of other transport options.
9. Describe the patient's medical condition that necessitates the use of an Ambulette in clear and understandable terms.
10. Determine the expected duration for which the patient will need an Ambulette and check the appropriate box for either temporary or permanent transport.
11. Optionally, add any other comments or explanations regarding the transport if necessary.
12. Fill in the attending practitioner's name and provider number, ensuring accuracy and compliance with Medicaid requirements.
13. Finally, the attending practitioner or authorized representative must sign and date the form to validate the certification.
14. Once all information is complete, users can save changes, download, print, or share the form as needed.

Complete your paperwork online today to ensure prompt processing of your Ambulette services.