Form Mnr-Nat - Masshealth Medical Necessity Form For Wheelchair Van Transportation

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MASSHEALTH MEDICAL NECESSITY FORM
NONEMERGENCY AMBULANCE/WHEELCHAIR VAN
FOR
THE COMMONWEALTH OF MASSACHUSETTS
Executive Office of Health and Human Services
TRANSPORTATION
MassHealth pays only for medically necessary nonemergency ambulance and wheelchair van transportation. The transportation provider
is responsible for the completeness of this form and must retain the form for six years from the date of service. Pursuant to 130 CMR
450.205, the transportation provider must provide completed forms if the MassHealth agency requests them. The MassHealth agency will
not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable
under MassHealth. Please complete each section and field relevant to the service being provided. Fields that are not applicable to the service
provided may be left blank.
1. Trip Information
Number of trips requested
Transportation requested
Wheelchair Van
Nonemergency Ambulance
X
Date(s) of service (recurring transportation can only be authorized for up to a 30-day period, beginning with the date of the first trip):
Medical service provided to member at destination
2. MassHealth Member Information
Name
MassHealth ID Number
Date of Birth
/
/
Gender
M
F
3. Pick-up Location
Is pick-up location member’s residence?
Yes
No
Is pick-up location a health care facility?
Yes
No
Facility Name (if pick-up location is a health care facility, including a facility at which member resides)
Street Address
City
State
Zip
4. Destination Information
Is destination member’s residence?
Yes
No
Is destination a health care facility?
Yes
No
Facility Name (if destination is a health care facility, including a facility at which member resides)
Street Address
City
State
Zip
5. Transportation Provider Information
Name
National Ambulance, LLC
1710910971
NPI or PIDSL
Tel. #
413-736-0092
Fax #
413-736-0079
MNR-NAT (07/16)
continued on back

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