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Get Part B: Health Care Provider Certification - Mts Access ...
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How to fill out the Part B: Health Care Provider Certification - MTS Access online
This guide provides clear and detailed instructions on how to complete the Part B: Health Care Provider Certification for MTS Access online. It is essential to provide accurate and complete information to ensure the applicant’s eligibility for paratransit services.
Follow the steps to successfully complete the form.
- Press the ‘Get Form’ button to obtain the Part B: Health Care Provider Certification form and open it in your preferred document editor.
- Begin by filling out the health care provider information. This includes your name, institution or facility, license number, specialization, address, phone number, email address, and the state issued.
- In Section 1, provide the diagnosed conditions along with the corresponding ICD-9CM and/or DSM codes.
- Indicate the length of time you have been treating the patient and the date of the last appointment.
- Specify the expected duration of the disability by selecting either 'Short Term' or 'Long Term' based on the criteria provided.
- State whether the applicant's disabilities prevent them from independently using the accessible MTS fixed route service, providing an explanation if applicable.
- List any mobility aids or devices the applicant requires by checking all relevant options provided.
- If the applicant is currently on medication, indicate if the side effects would hinder their ability to use the accessible services, providing additional details if necessary.
- For questions 10-22, answer 'Yes', 'No', or 'Sometimes' to indicate any challenges the applicant faces with transit and elaborate as required.
- In the final section, provide any additional factors related to the applicant’s disability that may affect their ability to use the transit services.
- Complete the certification section by signing and dating the form, ensuring it is filled out within 60 days of the in-person assessment.
- Review all responses for completeness and accuracy before saving changes, and consider downloading, printing, or sharing the form as needed.
Complete the Part B: Health Care Provider Certification online to help your patient access necessary paratransit services.
MTS Access is a shared ride service. Other passengers may be picked-up and dropped-off during your trip. If you reside outside the MTS ADA service area, your service is restricted to trip origins and destinations within our ADA service area.