Get 8002900523

Filling out the 8002900523 form requires attention to detail and understanding of the client’s medical needs. This guide provides step-by-step instructions to ensure the process is straightforward and user-friendly.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether an ambulance is the only appropriate means of transport by selecting 'Yes' or 'No'. If 'No' is chosen, this client does not qualify for non-emergency ambulance transport.
3. If 'Yes', proceed to fill out the remainder of the form. Start with the 'Date Request Submitted' field.
4. Complete the 'Requesting Provider' information by entering the provider's name, TPI, NPI, Taxonomy, contact name, phone number, and fax number.
5. Fill in the 'Ambulance Provider Name' and their identifier.
6. Provide the member's information, including their last name, first name, middle initial, date of birth, and Medicaid client number.
7. Document the member’s current condition affecting transport. Specify diagnoses and check any applicable conditions that require monitoring.
8. For conditions marked with an asterisk, provide additional details regarding the client’s needs that necessitate ambulance transport.
9. State the reason for transport and whether it is for hospital discharge, including the expected transport time.
10. Indicate the origin and destination of the transport, as well as the method of transport selected: Ground, Fixed Wing, Helicopter, or Specialized Vehicle.
11. Enter the Begin Date and End Date for the transport needs, along with the frequency of transportation required.
12. Review and certify that the information provided is true and accurate. Fill in your name, title, provider identifier, sign, and date the form.
13. Once all the relevant information has been entered and verified, save changes, and if necessary, download, print, or share the completed form.

Complete your documents online for an efficient process.