Get Mtm Distance Verification Form

This guide provides clear instructions on how to complete the Mtm Distance Verification Form online. By following these steps, users can ensure that all necessary information is provided accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to acquire the form and open it for editing.
2. Enter the member’s name prominently at the designated field.
3. Input the member’s date of birth (D.O.B.) to help verify their identity.
4. Fill in the member’s ForwardHealth ID number to ensure accurate processing.
5. Provide the appointment date to schedule the necessary healthcare services.
6. Complete the section for referring or rendering health care provider, including their name and phone number.
7. Describe the reason why the member cannot attend a closer healthcare provider.
8. Document the specific medical diagnosis related to the member’s request.
9. Indicate whether this is a one-time authorization or ongoing treatment and specify any end date if applicable.
10. Have the referring/rendering health care provider sign and date the form.
11. Include the National Provider ID and the address of the referring/rendering health care provider.
12. Ensure to fax the completed form at least 2 business days prior to the appointment using the provided fax number.
13. Finally, review all entries for accuracy, save the changes, and share the form if necessary.

Complete your forms online today for a smooth and efficient process.