Medical Certificate Of Transportation Services
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1Medical Certificate of Transportation Services
This document must be completed by a licensed medical professional; it cannot be completed by a non-emergency medical transportation provider.
PARTICIPANT INFORMATION
Name
Date of Birth
Medicaid Number
Date Approval Is Valid From*
Date Approval Is Valid Until*
*If approval is only for one appointment, enter the appointment date in both fields.
Please select all applicable boxes below:
Medically Necessary Attendant
Bariatric Wheelchair Van Service
If selected, indicate which of the following applies:
Select if the participant is wheelchair bound and has their own
wheelchair for transport. To qualify, participants must weigh more
Participant requires assistance during transportation due
than 250 lbs, or the wheel base of their wheelchair must be greater
to a physical disability
than 32 inches.
Participant requires assistance while being transported
due to a developmental disability
Wheel base of the patient’s wheelchair?
Participant requires assistance while being transported
due to cognitive issues
Approximate weight of the wheelchair?
Stretcher Van Service
Bariatric Stretcher Van Service
Select if the participant is unable to be transported in a sitting
Select if the participant is unable to be transported in a sitting
position, but does not require any medical interventions during
position, but does not require any medical interventions during
transport.
transport. To qualify, participants must weigh more than 250 lbs.
Participant’s height and weight?
Participant’s height and weight?
Transportation Service Over 200 Miles
Select if the participant
is not able to receive treatment through a
closer physician or facility.
Please explain why the participant requires the selected mode of transportation and/or attach any relevant documentation.
MEDICAL PROVIDER INFORMATION
I affirm that the above statements are true and accurate to the best of my knowledge and that state and federal funds will be used for the
services I am requesting on behalf of my patient and the most medically appropriate service is being requested.
Name and Title of Licensed Medical Provider
Phone Number
Signature
Date
**Please FAX your form to: 1-855-667-2557.
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