Nyc Medicaid Trip Order Form From One Medical Practitioner Referring An Enrollee To Second Medical Practitioner


Referral to Another Medical Site Transportation Request Fax Form (4/26/2012)
NYC Medicaid Trip Order Form from One Medical Practitioner Referring an Enrollee to Second Medical Practitioner
Questions? Contact LogistiCare Facility Services Department 877 564-5925
Trip Date: ________________
Appointment Time: _______________
Pick –Up Time: ________:________AM/PM
Return Time: ________:________AM/PM
(If return time is unknown enter 23:59)
Preferred Transportation Provider: _______________________________________________________________________________
Mass Transit
Ambulette Ambulatory
Ambulette Wheelchair
BLS Ambulance
ALS Ambulance
Enrollee Name
Medicaid ID Number
: ______________________________________________________________________________________
: ____________________________________
Enrollee Pick-Up Address
: __________________________________________________________________________________________
Phone Number: ______________________
Destination Facility: ___________________________________________________________________________NPI#: _____________________
Phone Number: ______________________
Address: ________________________________________________________________________________________________________________________________________________________
Destination Physician’s Name: _________________________________________________________________
CERTIFICATION STATEMENT: I (or the entity making the request) understand that orders for Medicaid-funded travel may result from the completion of this form. I (or the entity making the request)
understand and agree to be subject to and bound by all rules, regulations, policies, standards and procedures of the New York State Department of Health, as set forth in Title 18 of the Official Compilation of
Rules and Regulations of New York State, Provider Manuals and other official bulletins of the Department, including Regulation 504.8(2) which requires providers to pay restitution for any direct or indirect
monetary damage to the program resulting from improperly or inappropriately ordering services. I (or the entity making the request) certify that the statements made hereon are true, accurate and complete to
the best of my knowledge; no material fact has been omitted from this form.
Referring Physician's Name (PRINT)
Telephone #
Name of the referring medical practice, hospital or clinic
Referring Medical Practitioner's Address
Indicate name of nurse/social worker or other person who
Telephone #
assisted in completing this form
Referring Physician’s Signature
Fax three days prior to appointment – Brooklyn 877-585-8758 Queens 877-585-8759 Manhattan 877 585-8760 Bronx 877 585-8779 Staten Island 877 585-8780


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Parent category: Medical