Form Pt-1 - Masshealth Prescription For Transportation Form printable pdf download

Return completed form to: MassHealth Transportation Unit, P.O. Box 45, Boston, MA 02112-0045, or fax it to 617-988-2925.

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.

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

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

If Yes, please describe specific medical reason:

7. Other Information

Is a wheelchair van needed?

Yes

Is an escort accompanying the member for assistance with ambulation or to accompany a minor?

Yes

Specify other transportation needs:

8. Provider/Dental TPA Signature

Signature:

Date:

Please check applicable title:

DDS

RNP

RNC

Other (Specify 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. 05/09)

Form Pt-1 - Masshealth Prescription For Transportation Form

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