Form Pt-1 - Masshealth Prescription For Transportation Form (Page 2 of 2) in pdf

Instructions for Completing the Prescription for Transportation Form

Section 1 – Enter the member’s name, date of birth, MassHealth member ID, telephone number, and home address,

including apartment number, if applicable.

In certain circumstances MassHealth may authorize a member to be picked up at an address other than his/

her home address. If the member is to be picked up at an alternate address, enter the alternate address

information below the home address information. If there is a mailing address that is different from the home

address, enter that below the alternate pick-up address.

Section 2 – Enter the provider’s name, telephone number, address, MassHealth provider ID/Service location, and the NPI.

The provider requesting transportation must be a physician, physician’s assistant, nurse midwife, dentist, nurse

practitioner, psychologist, or managed-care representative, and an active MassHealth provider.

Section 3 – If the provider is also the treating provider, place a checkmark in the box labeled “Check if same as provider

listed in Section 2. ” If the treating provider is different from the provider filling out Section 2, enter that

provider’s name, telephone number, address and, if known, their MassHealth provider ID Service location,

and the NPI.

If the treatment destination is outside of the member’s locality (city or town of residence, or immediately

adjacent communities), indicate why the medical care is unavailable to the member within the member’s

locality.

Section 4 – Describe the specific medical care that will be provided.

Section 5 – Indicate how many weeks or months the member will require transportation, and how frequently the member

will be going per week or per month for the service. MassHealth will not authorize more than six months of

transportation for an acute illness, or one year of transportation for a chronic illness. For a single visit, enter “1”

week, and “1” visit per week.

Section 6 – Indicate if there is a medical reason that the member (or guardian, in accompanying the member) is unable

to use public transportation. Provide the specific physical or mental disability that prevents the member from

using public transportation.

Section 7 – Indicate if a wheelchair van or an escort is necessary.

Wheelchair van transportation may be provided for nonemergency medical services for members who use

a wheelchair or whose severe mobility impairments prevent them from traveling in a vehicle other than a

wheelchair van.

Section 8 – The signature of the physician, dental third-party administrator, physician’s assistant, nurse midwife, dentist,

nurse practitioner, psychologist, or managed-care representative is required to process the PT-1 form. The

signature certifies that the information contained on the form and any attachments, including medical

necessity information (per 130 CMR 450.204) is true, accurate, and complete to the best of the signatory’s

knowledge. Any falsification, omission, or concealment of any material fact contained on this form may result in

civil penalties or criminal prosecution.

For more detailed information about the MassHealth transportation benefit, consult the MassHealth

transportation regulations at 130 CMR 407.000. If you have any questions about completing this form, please

call the MassHealth Transportation Authorization Unit at MassHealth Customer Service at 1-800-841-2900.

Form Pt-1 - Masshealth Prescription For Transportation Form Page 2