Get Medical Necessity Form - Logisticare Inc

Filling out the Medical Necessity Form for Logisticare Inc is an essential step in ensuring appropriate transportation services for members in need. This guide provides clear and detailed instructions to assist you in completing the form accurately and efficiently online.

Follow the steps to fill out the Medical Necessity Form.

1. Press the ‘Get Form’ button to obtain the Medical Necessity Form and open it for editing.
2. Begin by entering the member's name and date of birth in the designated fields to ensure the information is linked to the correct individual.
3. Input the member's Medicaid number accurately. This identification is crucial for service providers.
4. Indicate whether the member can ambulate without assistance by selecting ‘Yes’ or ‘No’.
5. Specify if the member uses a walker or cane by checking the appropriate box.
6. Determine if the member requires a wheelchair and mark the corresponding option.
7. Assess the member’s ability to transfer and mark either ‘Yes’ or ‘No’.
8. If applicable, indicate if the member is bedbound by fulfilling the criteria and selecting the appropriate option.
9. Check if medical monitoring is required by the member by selecting ‘Yes’ or ‘No’.
10. Indicate whether the member requires oxygen and whether they can self-administer it.
11. Confirm if the member can act as their own responsible party.
12. State whether the member will have an escort during transportation.
13. Choose the mode of transportation required based on the member’s condition and mobility needs.
14. If applicable, provide the qualifying ICD9 or diagnosis in the designated field, especially if requesting specialized transport services.
15. Include any additional comments or details relevant to the member's transportation needs.
16. Ensure the physician completes and signs the form, providing their printed name and date for verification purposes.
17. After completing all sections, save the changes to your form. You can then download, print, or share the completed form as necessary.

Complete the Medical Necessity Form online today to ensure timely and appropriate transportation services.