Get Nonemergency Ambulance Transportation Prior Authorization Form Page 1 Of 2 Please Return Completed

Filling out the NonEmergency Ambulance Transportation Prior Authorization Form is essential for ensuring that users receive the necessary non-emergency transportation services. This guide will walk you through each section of the form, providing clear and supportive instructions.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in a suitable online editor.
2. Begin by entering the member's name in the designated field, followed by their ID number in the Member Information section.
3. In the Provider Information section, fill in the provider's name, Supplier ID or NPI number, provider's phone number, fax number, and contact name.
4. Enter the date of request and date of service in the indicated fields, along with any previous authorization number, if applicable.
5. Specify the place of service by providing the city/town or facility associated with the transportation.
6. In the Clinical Information section, indicate the required units and enter the appropriate CPT codes, along with the diagnosis and associated diagnosis code.
7. Select the type of ambulance needed, whether stretcher or wheelchair, and provide details about who requested the ambulance.
8. Fill in the place of origin and destination fields with the necessary information.
9. In the Medical Necessity Information section, specify the treating clinician's name and address if available, or leave blank for Neighborhood to obtain this information.
10. Describe the medical conditions preventing safe transportation by any other means and indicate the purpose of transfer.
11. Review the criteria for medical necessity and check all applicable boxes that describe the member's situation.
12. Complete any additional authorizations required by reviewing the Neighborhood Decision section, noting that authorization does not guarantee payment.
13. Finally, save your changes, then download, print, or share the filled-out form as necessary.

Complete your NonEmergency Ambulance Transportation Prior Authorization Form online to ensure timely processing and approval.