Form Pt-1 - Masshealth Prescription For Transportation Form
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1
2MASSHEALTH PRESCRIPTION FOR TRANSPORTATION FORM
Please indicate the type of request:
New form
Renewal
Increase in visits
Alternate pick-up addre ss
Commonwealth of Massachusetts • EOHHS
Please print or type all information.
Reset Form
1. MassHealth Member Information
Last name
First name
Date of birth
Member ID
Tel. no.
HOME ADDRESS (The MassHealth member will be transported to and from this address, unless an alternate pick-up address is listed.)
Street address
Apt. no.
City/Town
State
Zip
ALTERNATE PICK-UP ADDRESS
Street address
Apt. no.
City/Town
State
Zip
MAILING ADDRESS (If different from Home address.)
Street address
Apt. no.
City/Town
State
Zip
(Section to be completed by the provider requesting transportation.)
2. MassHealth Provider Information
Name of treating provider/facility
Tel. no.
Ext
Street address
Suite no.
City/Town
State
Zip
MassHealth Provider ID/Service location
NPI
3. Name and Location of Treating Provider/Facility (Indicate where the MassHealth member will be seen.) Check if same as provider listed in Section 2.
Name of treating provider/facility
Tel. no.
Ext
Street address
City/Town
State
Zip
MassHealth Provider ID/Service location
NPI
Is the treating facility within the member’s locality (city or town of residence, or adjacent city or town)?
Yes
No
If No, please justify:
4. Medical Treatment Type
Please list the MassHealth-covered service(s) that the member is receiving at this location.
5. Duration and Frequency of Treatment
How long will the MassHealth member require these services?
week(s)
month(s)
How frequently will the MassHealth member be seen for this service?
visit(s) per week
visit(s) per month
6. Why Transportation Services Are Required
Is there a medical reason why the member (or guardian if accompanying a minor) is unable to use public transportation?
Yes
No
If Yes, please cite specific medical reason:
7. Other Information
Is a wheelchair van needed?
Yes
No
Is an escort accompanying the member for assistance with ambulation or to accompany a minor?
Yes
No
Specify other transportation needs:
8. Provider Signature
Signature:
Date:
Please check appropriate title:
MD
DDS
RNP
RNC
Other Please list title:
Do not write below this line • MassHealth use only
APPROVED. Authorization expires on:
Tracking no.:
DENIED. Reason:
MassHealth Authorized Signature:
Date:
PT-1 (Rev. 03/09)
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