Physician Referral Form

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Physician Referral Form
The Department of Vermont Health Access (DVHA) helps people on Medicaid or Dr. Dynasaur with
transportation to get to their medical appointments or pick up prescriptions. If the requested trip is
over 60 miles from a member’s home, please complete and sign this form in order for us to determine
if this trip should be covered by Medicaid. Please mail or fax the form to:
Medicaid Transportation
DVHA
312 Hurricane Lane, Suite 201
Williston, VT 05495
Fax: (802) 879-5919
Client Name: ________________________________________________________________
Medicaid Unique ID: _______________________ DOB: _____________
Appointment Date and Time: ____________________________________________________
Name of Primary Physician: ____________________________________________________
Name of Physician to whom
____________________________________________________
Client is Being Referred:
If Applicable, Facility Name: ____________________________________________________
Address: ____________________________________________________
____________________________________________________
Phone: _________________________
Is overnight lodging necessary outside of a hospital?
Yes
No
If yes, please specify the dates requested for lodging: ______________________________________
Medically, how many people should accompany the patient (other than the driver)? ______________
Please explain on next page.
Local Transportation Provider:
Address:
Phone:
DVHA Decision: Approved
Denied
Authorized by: _____________________________________________________ Date: ___________

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