Get Gchp Nemt Prescription/attestation Of Medical Necessity 2015

Completing the GCHP NEMT Prescription/Attestation of Medical Necessity form is a crucial step in securing transportation services for medical appointments. This guide provides clear, detailed instructions on how to effectively fill out the form online to ensure your submission is complete and timely.

Follow the steps to fill out the GCHP NEMT form correctly

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the patient's full name in the designated field.
3. Input the GCHP Member I.D. number, which identifies the member requesting transportation.
4. Specify the name of the servicing provider or facility responsible for the patient's care.
5. Provide the patient's preferred contact number for any follow-up regarding this request.
6. Indicate the date of service for authorization, ensuring it falls within a one-year timeframe based on member eligibility. Fill in the 'From' and 'To' fields correctly.
7. Mark all days of the week that transportation will be needed for the appointments listed.
8. Describe the diagnosis specific to the visits to assist in justifying the necessity for transportation.
9. Explain the medical purpose for the visit(s) in detail.
10. Indicate how the patient mobilizes, selecting the appropriate option and providing details if 'Other' is chosen.
11. List any functional limitations that prevent the patient from ambulating without assistance or from using private or public transportation.
12. Confirm that the patient has no transportation resources by marking the relevant options.
13. Require the provider's signature, ensuring it is included in the designated field.
14. Enter the date of the provider's signature.
15. Print or type the provider's name in the appropriate section.
16. Include the provider's license number to validate credentials.
17. Provide the provider’s specialty for further clarification of their qualifications.
18. Input the provider’s telephone number with the area code to ensure contact can be made.
19. Enter the provider's complete address, including street, city, and zip code.
20. Once all fields have been completed accurately, save changes, and consider exporting the form to download, print, or share as necessary.

Start completing the GCHP NEMT Prescription/Attestation of Medical Necessity form online today to secure necessary transportation services.