Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling out the insurance type, followed by the member’s name and gender. Ensure the member's name is written as it appears on their insurance documents.
3. Enter the member’s insurance ID number and date of birth in the format ___/___/___ to ensure clarity.
4. Proceed to the appointment information section. Select the appointment days by marking the appropriate checkboxes for each day of the week and specify the appointment and return times.
5. In the level of service section, choose the correct options such as ambulatory, wheelchair, BLS, mass transit, stretcher, ALS, or gas reimbursement. If selecting stretcher, BLS, or ALS, provide necessary precautions.
6. Fill in the start and end dates for the service, as well as ongoing service details if applicable.
7. Indicate if there are any special needs the member may have and whether they can sign the driver’s log. Specify if the signature status will be permanent by selecting ‘Yes’ or ‘No’.
8. Complete the physician’s signature section as needed.
9. Continue to the pick-up information section. Provide the name, phone number, and address of the facility or complex involved.
10. Fill out the drop-off information with the same details for the destination facility and include the treatment type, selecting from options like dialysis, substance abuse, mental health, or adult day care.
11. Lastly, complete the ordering party’s information, including their name, title, and contact phone and fax numbers. Ensure to sign and date the form.
12. Once all sections are filled out accurately, save the changes, download, print, or share the completed form as needed.

Start filling out the Modivcare Solutions IL Standing Order Form online today for a seamless experience.