Logisticare Level Of Service Certification Of Medical Necessity

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GA Operations
1640 Phoenix Blvd. Ste. 200
College Park, GA 30349
LEVEL OF SERVICE CERTIFICATION OF MEDICAL NECESSITY
Required for All Patients / Members Using Stretcher Transport
UR F
# 877-601-0615
AX
P
# 800-486-7642
HONE
Patient / Member Information:
Medical Provider Information:
DOB:
Sex
Age
Medicaid ID #
Medicaid Provider #
Phone #
M F
(
)
____/___/___
Patient Name (Last, First, MI)
Medical Provider Name & Address
Nature of Appointment:
LEVEL OF SERVICE REQUIRED BY PATIENT / MEMBER & PRESCRIBED BY MEDICAL PROVIDER
Stretcher 
Oxygen: Y
 N
; I
ADMINISTER?
ES
O
F YES CAN THE MEMBER
The following criteria must be met and applicable to the condition of the patient / Member at the time stretcher services are
provided :(check all that apply)
__ Bed confined
__ Unable to walk
90 Days (RN) 
1 year (Physician/PA) 
Estimated duration of level of service: (check one)
If a Registered Nurse signs this form it is valid for 90 days. A physician or physician’s assistant may request certification for
up to 365 days.
Please describe the Member’s disabling physical condition after treatment that makes transportation by stretcher medically
necessary (i.e., dialysis, chemotherapy.)
I understand that any falsification or omission of material fact stated may subject me to penalties by the Department of
Community Health when submitting letters of medical necessity related to the NET programs. If you have any questions
please contact LogistiCare’s Facility Assistance Department at 800-486-7642
I certify that to the best of my knowledge, the above information is true, accurate and complete and the level of service
required for the patient’s / Member’s transport is medically necessary for the patient’s / Member’s health.
Physician, PA or RN : PRINTED NAME/TITLE: ________________________________________________
SIGNATURE: ________________________________________________
DATE: ________________
This form should be completed by the attending physician or his designated staff confirming stretcher is necessary as
indicated above. Only a Physician, a Physician’s Assistant or Registered Nurse, at the direction of a physician my sign the
form above.
Revised 9/15/2015

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