Get Request For Transportation Outside The Common Medical ...

Filling out the Request for Transportation Outside the Common Medical Marketing Area form is an essential step for Medicaid enrollees needing transportation for medical services unavailable locally. This guide will provide you with clear, step-by-step instructions to ensure that your form is completed accurately and efficiently.

Follow the steps to successfully fill out your form.

1. Press the ‘Get Form’ button to acquire the form and open it in your editor.
2. Begin by entering the patient's personal information, including their name, Medicaid number, and date of birth in the designated fields to ensure proper identification.
3. Indicate whether you are the referring physician by selecting either 'YES' or 'NO'. This is essential for understanding the context of the referral.
4. Next, answer whether the medical service needed is available locally by selecting 'YES' or 'NO'. This helps the Medicaid program assess the necessity for transportation.
5. If the services are available locally, provide a detailed explanation of why those services are inappropriate for the enrollee in the specified space. Include specific reasons to prevent any delays in processing.
6. Indicate whether the referral is to see a specialist by selecting 'YES' or 'NO'. If 'YES', provide details about the specialist, including their name and service location.
7. Determine whether multiple appointments will be needed by selecting 'YES' or 'NO'. This information is crucial for the scheduling of transportation.
8. Indicate if the referral is for Primary Care, Mental Health, Physical Therapy, lab work, or an Independent Medical Exam by selecting 'YES' or 'NO'.
9. Complete the referring physician's information including their name, NPI number, facility name, address, and contact information.
10. Include the name and title of the staff member who assisted in completing the form, along with their contact number.
11. The referring physician must sign and date the form, confirming that the details provided are accurate.
12. Finally, review the form for accuracy, save your changes, and choose to download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing of your transportation requests.