Get Iehp Transportation Request Form (snf & Ltc) 2017-2025

Filling out the IEHP Transportation Request Form (SNF & LTC) online is a straightforward process designed to ensure that individuals receive the transportation they need for medical appointments. Follow this guide to navigate through each section of the form effectively.

Follow the steps to complete the transportation request form properly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by entering today's date in the designated field. This is essential for tracking your request.
3. Input the IEHP ID number, which is crucial for identifying the member in the system.
4. Fill in the member's full name, height, and weight. Note that height and weight are required only if the member will be using a wheelchair or gurney.
5. Indicate if there are any special needs, such as tracheostomy to ventilator connection or suctioning requirements.
6. For oxygen requirements, select 'Yes' or 'No' and fill in the liter flow, specifying whether it is deep, mild, or shallow.
7. In the transportation from section, provide the facility name, room number, and the complete address, including city and zip code. Also, include the contact person's details.
8. Next, in the transportation to section, fill in the doctor's name or facility, room number if applicable, the address, city, and zip code.
9. Complete the appointment section by providing the appointment date and appointment time, ensuring that the request is submitted within five business days of the appointment. Include details for dialysis days as necessary.
10. Select the mode of transport required, such as ambulatory, wheelchair, or gurney, and specify any necessary equipment or assistance needed.
11. Lastly, review all entries for accuracy. Once confirmed, save your changes. You may choose to download, print, or share the completed form as needed.

Submit your transportation request form online to ensure timely transportation for your medical appointments.