Get Part B: Health Care Provider Certification

Filling out the Part B: Health Care Provider Certification is a crucial step for healthcare providers to assist their patients in accessing essential paratransit services. This comprehensive guide will walk you through each section of the form, ensuring clarity and accuracy in your submissions.

Follow the steps to complete the certification effectively.

1. Press the ‘Get Form’ button to access the Part B: Health Care Provider Certification form online.
2. Begin by printing the name of the health care provider in the designated field. Ensure that all information is legible and accurate.
3. Fill in the institution or facility name where you provide care to the applicant. Include your professional license number and specialization.
4. Complete the contact details, including street address, city, state, zip code, phone number, and email address.
5. Record the state where your license was issued.
6. Provide written diagnosis or diagnoses along with the relevant ICD-9CM or DSM codes in the specified section.
7. Indicate how long you have been treating the applicant by filling in the duration of the treatment.
8. Document the date of the last consultation with the applicant to reflect ongoing medical support.
9. Specify the expected duration of the applicant’s disability by selecting either short-term or long-term.
10. Answer whether the applicant’s disability prevents independent use of the accessible MTS transit services. Elaborate on how their health conditions impact independent travel.
11. In this section, indicate any mobility aids or devices the applicant uses. Please check all that apply.
12. Assess if any prescribed medications may hinder the applicant’s ability to use the accessible transit services. Provide explanation if applicable.
13. For questions 10-22, respond to each item and provide explanations as needed. Use the format of Yes, No, or Sometimes to indicate impacts.
14. In the final section, provide any additional factors related to the applicant's disability that impact their ability to utilize the transit service.
15. Complete the certification statement, including your signature and the date. Ensure that all information is truthful and complete.
16. Once all sections are completed, save your changes, and options will be available for downloading, printing, or sharing the form as required.

Start filling out the Part B: Health Care Provider Certification online now for a smooth application process.