Texas Medicaid And Children With Special Health Care Needs (Cshcn) Services Program Non-Emergency Ambulance Prior Authorization Request
ADVERTISEMENT
1
2
3Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
Submit completed form by fax to: 1-512-514-4205
Requesting Provider Information
Provider Name:
Date Request Submitted:______/______/______
TPI:
NPI:
Taxonomy:
Contact Name:
Phone: ______-______-_______
Fax: ______-______-_______
Ambulance Provider:
Ambulance Provider Identifier:
Client Information
Client Name (Last, First, MI):
Date of Birth:______/______/________ Client Medicaid/CSHCN Number:
Client weight:
Is the client morbidly obese?
Yes
No
Are all other means of transport contraindicated?
Yes
No
If no, this client does not qualify for non-emergency ambulance transport.
If yes, please complete the remainder of the form.
Is the client currently an inpatient at a hospital facility?
Yes
No
If yes, this client does not qualify for non-emergency ambulance transport.
If no, please complete the remainder of the form.
Note: Any ambulance transports for clients who are inpatient at a hospital are the responsibility of the hospital. One time
ambulance transports that are related to a hospital discharge may be considered for prior authorization.
Client’s Current Condition Affecting Transport - Check Each Applicable Condition
Physical or mental condition affecting transport:
Client requires monitoring by trained staff because:
Oxygen (portable O2 does not apply)
Airway
Suction
Cardiac
Comatose
Life support
Behavioral
The client is able to sit in which of the following while up during the day:
Wheelchair
Geri-Chair
Cardiac Chair
None – Client not able to sit up
How does this client transfer? Assisted
Unassisted
If able to sit up, for how long:
Is the client able to stand unassisted?
Yes
No
If No, select one that applies:
Assist of one
Assist of two
Does the client use an assistive walking device?
Yes
No
The client is “bed-confined” (i.e. unable to sit in a chair, stand and ambulate)?
Yes
No
If the client is bed-confined explain the functional, physical and/or mental health condition indicated for a transport:
Does the client pose immediate danger to self or others?
Yes
No
If YES, explain the circumstances:
Does the client require physical restraint during transport above ambulance standards?
Yes
No
If Yes, select type of restraint:
Wrist
Vest
Straps (not associated with ambulance standards)
Other:
Effective Date_06132014/Revised Date_06132014
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance
Medical
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance
Legal
Related Categories
Parent category: Medical