Get Nonemergency Ambulance Prior Authorization Request

Completing the Nonemergency Ambulance Prior Authorization Request online is a crucial step for obtaining necessary transportation services. This guide provides a detailed breakdown of each section to ensure users can complete the form accurately and efficiently.

Follow the steps to successfully complete the Nonemergency Ambulance Prior Authorization Request.

1. Press the ‘Get Form’ button to obtain the Nonemergency Ambulance Prior Authorization Request form and open it in your preferred editor.
2. In the Requesting Provider Information section, enter the name of the entity requesting the authorization, such as a hospital, nursing facility, or physician. Be sure to include your Texas Provider Identifier (TPI), National Provider Identifier (NPI), taxonomy code, contact name, phone, fax, and ambulance provider details.
3. Fill in the Client Information section, including the client's full name (last, first, middle initial), date of birth, Medicaid/CSHCN number, and weight. Indicate if the client is morbidly obese and whether they are currently an inpatient at a hospital.
4. Complete the Client’s Current Condition section by checking each applicable condition affecting transport and providing detailed explanations where necessary, including how the client transfers and their mobility status.
5. If applicable, provide information regarding any extra attendants required during transport and the reason for the requested transport, whether for hospital discharge or other purposes.
6. Indicate the method of transport, whether ground, fixed wing, helicopter, or specialized, and specify the request type, either one-time or recurring, along with the expected number of days for recurring requests.
7. In the Certification section, ensure that the form is signed and dated by the authorized person, entering their name, title, and signature, and providing the corresponding TPI or NPI number.
8. Once all sections are completed, review the form for accuracy. Users can then save changes, download, print, or share the completed document as needed.

Take the next step in securing essential transport by completing your Nonemergency Ambulance Prior Authorization Request online today.