Get Standing Order Form - Repeating Appointments

This guide provides a clear and supportive overview of how to complete the Standing Order Form for Repeating Appointments online. By following these steps, users will be able to accurately fill out the necessary information for effective appointment management.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Standing Order Form. This will allow you to open it in your digital document editor.
2. Enter the date of the request in the designated field.
3. Input the Medicaid member’s name and Medicaid number accurately, ensuring that all information is correct.
4. Select the region or county from which the service is requested.
5. Fill in the date of birth of the Medicaid member.
6. Mark the days of the week when appointments are required by checking the appropriate boxes.
7. Specify the start date for the repeated appointments.
8. Choose the level of service by selecting whether the member is ambulatory or requires a wheelchair. If applicable, enter the weight for wheelchair service.
9. Indicate whether an escort or car seat is required for the Medicaid member.
10. Enter the name of the person requesting the service, their relationship to the Medicaid member, and their phone number.
11. Describe the patient’s condition clearly and in detail.
12. Input treatment type and treatment procedure codes as required, ensuring accuracy.
13. Provide the facility's Medicaid ID number for proper identification.
14. Fill out the pick-up and destination information, including addresses, city, state, and zip code.
15. Specify the appointment time and the desired pick-up time.
16. Indicate where the individual will be dropped off, including a full address and expected destination.
17. Provide the physician’s name and any necessary directions.
18. Indicate whether the transportation is one-way or round trip.
19. Enter the patient’s authorization expiration date.
20. The licensed physician or certified professional must sign the form, affirming the accuracy of the information provided.
21. Once all fields are completed, save the changes to the form. You can then choose to download, print, or share the completed form.

Start completing your Standing Order Form - Repeating Appointments online today.