Verification Of Medicaid Transportation Abilities Form printable pdf download

Form 2015 (5/2015)

Maintain Original in Medical Record

VERIFICATION OF MEDICAID TRANSPORTATION ABILITIES

Patient Name: _________________________________

Patient Date of Birth __/__/____

Patient Medicaid Number: _______________________

Patient Telephone: _____________________________

Patient Address: _____________________________________________________

Can the patient use public transit? Yes

If you checked NO, please proceed to #2.

In the left column below, please check the medically necessary mode of transportation you deem appropriate for this patient:

a) Taxi: The patient can get to the curb, board and exit the vehicle unassisted, or is a collapsible wheelchair user who can approach the vehicle and

transfer without assistance, but cannot utilize public transportation.

b) Ambulette Ambulatory: The patient can walk but requires assistance.

c) Ambulette Wheelchair: The patient is a wheelchair user, requires lift-equipped or roll-up wheelchair vehicle and assistance.

d) Stretcher Van: The patient is confined to a bed, cannot sit in a wheelchair, and does not require medical attention/monitoring during transport.

e) BLS Ambulance: The patient is confined to a bed, cannot sit in a wheelchair, and requires medical attention/monitoring during transport for reasons such

as isolation precautions, oxygen not self-administered by patient, sedated patient.

f) ALS Ambulance: The patient is confined to a bed, cannot sit in a wheelchair, and requires medical attention/monitoring during transport for reasons such

as IV requiring monitoring, cardiac monitoring and tracheotomy.

If you selected letter (a-f) above, please use the space below to justify the corresponding mode of transportation by providing the following required information:

a. Enter all relevant medical, mental health or physical conditions and/or limitations that impacts the required mode of transportation for this patient.

b. Enter the level of assistance the patient needs with ambulation. (Example – patient requires 2 person assistance, patient requires 1 person assistance etc.)

c. Enter the corresponding housing situations that may impact the patient’s ability to access the selected mode of transportation. (Example – wheelchair bound

patient resides on the 2

floor of a building with no elevator)

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Verification Of Medicaid Transportation Abilities Form

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