Get Logisticare Standing Order Request Form 2009-2026

Filling out the LogistiCare Standing Order Request Form online can be a straightforward process when you have clear guidance. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the LogistiCare Standing Order Request Form in your preferred format.
2. Begin by entering the member’s name, date of birth, and gender in the designated fields.
3. Provide the Forward Health number and, if applicable, the parent or guardian’s name along with their phone number.
4. Select the appointment days the member will require transportation by checking the appropriate boxes.
5. Fill in the start date of services needed.
6. Indicate the level of service required based on the member’s mobility and needs.
7. Identify who is requesting the service with their relationship to the member along with their contact phone number.
8. State the patient’s condition and the facility’s NPI number, along with treatment type and procedure codes if applicable.
9. Answer whether the member can sign the driver’s log and provide further details if they cannot.
10. Enter the name and phone number of the current transportation provider.
11. Specifically denote whether the pickup location is a home or a facility, providing the address details.
12. Confirm the member’s pickup address, noting any specifics that may change frequently.
13. Fill in the appointment time and suggest a pickup time from the member’s home.
14. Provide the drop-off details including the facility name, contact person, address, and directions if necessary.
15. Specify the return pick-up time and whether the trip is one-way, round trip, or three-way.
16. Complete the authorization section by affirming the accuracy of information provided and signing the form.
17. After finishing the form, save your changes and consider downloading or printing the form for your records.
18. Finally, share the completed form as necessary or fax it to the designated Wisconsin Facility Department.

Complete your LogistiCare Standing Order Request Form online today for efficient non-emergency medical transportation.