Follow the steps to fill out your form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Fill in the first name, last name, date of birth, and Medi-Cal number or CIN#. Indicate the living arrangement by checking the appropriate option: home, board and care, or ICF-DD.
3. Next, provide the prescribing provider information. Enter the provider’s full name, phone number, NPI, and fax number. Include the facility name, fax number, contact name, and contact direct phone number.
4. Select the type of Non-Emergency Medical Transportation required by checking one of the boxes: ambulance, litter/gurney van, wheelchair van, or air ambulance. Include the NEMT provider name, provider NPI, and phone number.
5. Specify the anticipated duration of the transportation service. Indicate the start and end dates and choose the duration option: six months or twelve months.
6. In the justification section, provide medical documentation that details the specific physical and medical limitations experienced by the member. Include the diagnosis and ICD-10 code(s). Ensure to clarify how these limitations preclude the member’s ability to use standard transportation.
7. Check any additional conditions that apply, such as contraindications for using other forms of medical transportation or specific needs like wheelchair transport.
8. Finally, the form requires a certification statement signed by the authorized healthcare provider. This can include a physician, assistant, nurse practitioner, or other eligible professional. Ensure the signature and date are included.
9. Once the form is fully completed, save your changes, and choose to download, print, or share the finalized form as needed.

Complete your CalOptima Referral Request For Transportation Services and Physician Certification Statement (PCS) online today to ensure timely processing of your transportation services.