Get Caloptima Referral Request For Transportation Services And Physician Certification Statement (pcs) 2011-2025

This guide provides step-by-step instructions for completing the CalOptima Referral Request For Transportation Services And Physician Certification Statement (PCS) online. Ensuring accurate information helps facilitate the processing of transportation services efficiently.

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. Enter the patient's information in the MEMBER INFO section. This includes the patient name, date of birth, age, Medi-Cal number, and preferred language. Ensure all fields are correctly filled out.
3. Provide the patient's address and phone number in the relevant fields. Specify the residential type from the options provided, such as home, board and care, or other.
4. Complete the facility information if applicable, including facility name and contact details.
5. In the Primary Diagnosis section, enter the primary diagnosis and the corresponding ICD-9 code.
6. Indicate whether the member is under conservatorship by selecting 'Y' for yes or 'N' for no.
7. Complete the PRESCRIPTION AND MEDICAL NECESSITY CRITERIA section. Ensure that the prescribing physician's name, phone number, and address are filled in accurately.
8. Specify the date and time NEMT services are required as well as the name and phone number of the individual accompanying the patient.
9. Indicate the duration for which NEMT services are needed, along with details of the patient's current NEMT provider.
10. Mark the member's qualifying medical necessity criteria, and be sure to attach any required medical records to substantiate medical necessity.
11. Ensure the medical professional signs and dates the authorization section of the form.
12. After completing all sections, review the form thoroughly to ensure accuracy, then save changes, download, print, or share the form as needed.

Complete your CalOptima Referral Request For Transportation Services And Physician Certification Statement (PCS) online today.