Texas Medicaid And Children With Special Health Care Needs (Cshcn) Services Program Non-Emergency Ambulance Prior Authorization Request Page 2

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Texas 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
Continuous IV therapy or parenteral feedings *
Advanced decubitus ulcers *
Chemical sedation *
Contractures limiting mobility *
Decreased level of consciousness*
Must remain immobile (i.e., fracture, etc.) *
Isolation precautions (VRE, MRSA, etc.) *
Decreased sitting tolerance time or balance *
Wound precautions *
Active Seizures *
* Provide additional detail (i.e. type of seizure or IV therapy, body part affected, supports needed, or time period for the
condition) or provide detail of the client’s other conditions requiring transport by ambulance.
Extra Attendant
Reason:
Reason for Transport:
Hospital discharge?
Yes
No
If yes, expected transport time:
_____________________________________________
Other purpose?
Yes
No
Explain:________________________________________________________________
Origin:___________________________
Destination:____________________________________________________________
Method of Transport:
Ground
Fixed Wing
Helicopter
Specialized
Request Type:
One-time, Non-repeating
Recurring *
Number of days being requested:________days (2-60 days)
Begin Date: _____/______/______
* Physician signature required for recurring request.
NOTE: For an exception to the one-time or recurring request type refer to the Non-emergency Ambulance Exception request in the medical policy.
Reason For Repetitive Transport (2-60 day request type)
Dialysis
Radiation Therapy
Physical Therapy
Hyperbaric Therapy
Other (explain):
Estimated number of visits needed to go to dialysis or therapy? _______
Explain why the needed services could not be provided at less cost where the client is located:
Certification:
I certify that the information supplied in this document constitutes true, accurate, and complete information and is supported in
the medical record of the patient. I understand that the information I am supplying will be utilized to determine approval of
services resulting in payment of state and federal funds. I understand that falsifying entries, concealment of a material fact, or
pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law which can result in
fines or imprisonment, in addition to recoupment of funds paid and administrative sanctions authorized by law.
Name: __________________________________
Title: ________________
Provider Identifier: ______________
Signature: _______________________________________________________ Date Signed: ____/____/____
Effective Date_06132014/Revised Date_06132014
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