Get Eascare Med Nec.docx

Filling out the Eascare Med Nec.docx, the MassHealth Medical Necessity Form, is essential for securing nonemergency ambulance and wheelchair van transportation. This guide provides a step-by-step approach to completing the form accurately and ensures that users understand each section's requirements.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to download the Eascare Med Nec.docx document and open it in your online document editor.
2. In the first section labeled 'Trip Information', enter the number of trips requested and select the type of transportation needed by checking either 'Wheelchair Van' or 'Nonemergency Ambulance'. Specify the date(s) of service and the medical service provided at the destination.
3. Next, move to the 'MassHealth Member Information' section. Fill in the member's name, MassHealth ID number, date of birth, and gender.
4. Proceed to 'Pick-up Location'. Indicate if the pick-up location is the member's residence or a health care facility by selecting 'Yes' or 'No'. If it's a health care facility, include the facility name and the complete address.
5. In the 'Destination Information' section, determine if the destination is the member's residence or a health care facility. Provide the necessary details if applicable.
6. Fill out the 'Transportation Provider Information' section, ensuring to include the name of the transportation provider, NPI or PIDSL, and contact details.
7. Complete the 'Medical Necessity Information' based on the type of transportation requested. For wheelchair van requests, check the relevant conditions the member meets. For ambulance requests, similarly, indicate applicable medical conditions.
8. In the 'Requesting Provider Attestation', the provider must review and certify the information by signing the form and providing their details, including NPI and contact information.
9. After completing the form, ensure all required fields are filled accurately. Save your changes and choose to download, print, or share the form as necessary.

Begin filing your documents online today to ensure timely access to necessary transportation services.