Instructions To Complete The Statewide Provider Certification Form For Ambulatory And Wheelchair Transports printable pdf download

Instructions to Complete the Statewide Provider Certification Form for Ambulatory and Wheelchair Transports

Section 1 – Patient Information – May be Completed by Patient or Provider

Patient’s Name and Address

Enter the patient’s Last Name, First Name. A complete and correctly spelled name is crucial for proper patient

identification. Enter the patient’s home address. If the patient is a resident of an inpatient facility, enter the name

and address of the facility along with room and bed number.

Telephone Number

Enter the contact number for the patient (i.e. home telephone or cell number). If patient is a resident of an

inpatient facility, enter the inpatient facility telephone number.

Date of Birth

Enter the patient’s date of birth as mm/dd/yyyy.

Patient’s Social Security #

The patient’s social security number is optional.

Patient’s 11-digit MA #

Enter the patient’s 11-digit Medical Assistance number. Do not enter the MCO identification number.

Patient’s Medicare #

If applicable, enter the patient’s 9-digit Medicare number along with the applicable “letters”

Other Insurance

If applicable, enter other insurance information – ID number and name of other insurance

Section 2 – Must be Completed by Provider

Primary and Secondary Diagnosis

DO NOT ENTER ICD OR DSM code. Spell out primary and secondary diagnosis for which you are

providing treatment. Be as comprehensive as possible.

Associated Symptoms

Spell out symptoms of the condition. Providing this information may support the diagnosis, however, will not

provide medical justification for transportation. I.E. “Knee pain” does not medically justify the need for

transportation as it is a symptom.

Weight and Height

Enter weight in pounds and height in feet and inches.

Adjunctive Information

If applicable, check appropriate box

Other Relative Conditions

If applicable, check all that apply.

Section 3 – Must be Completed by Provider

Type of Medical Service

Enter the type(s) of medical service the patient is being transported for.

Duration of Treatment

Check appropriate box. If temporary, complete anticipated duration

Frequency of Appointments

Check appropriate box. If other, specify. Frequency of appointments scheduled helps determine eligibility of

Medicaid transportation services.

Section 4 – Must be Completed by Provider

Attendant

Check appropriate box. Is it medically necessary for the patient to have someone with them during the

transport/for the appointment?

Transit Services

Check appropriate box. If on a transit service line, is it possible for the patient to utilize either public, ADA or

paratransit transportation? Contact the transportation office if you need clarification on the types of bus

service.

Type of Transportation Needed

Check appropriate box. If ambulatory, enter distance if ability to ambulate is limited.

(Ambulatory/Wheelchair)

If wheelchair, can patient transfer? Check type of wheelchair, i.e. regular, electric, etc.

Check appropriate box for accessibility. Indicate number of steps, if applicable.

Provider’s Certification and Signature – Must be Completed by Provider

Provider Type

Check appropriate box. Note only physician, CRNP and dentist are “Authorized” to certify.

Signature of Provider

Signature of provider is mandatory or will be returned which will delay transportation services

Date Signed

Enter date signed. This form is valid for a period of one year from the date of signing unless the patient’s condition

warrants recertification.

Provider’s Medical

Enter Provider’s Medical Assistance or NPI #. This number is needed to verify provider’s participation in the Medicaid

Assistance or NPI #

program.

Provider’s Telephone #

Enter Provider’s telephone number. We may need to contact you.

Provider’s Full Address

Enter Provider’s full address. We will utilize this to transport the patient for the appointment.

For your convenience and to expedite services, you may fax the completed form to 443-643-0344. However, we must receive a form completed in

full with an original signature within 30 days. Incomplete forms will be returned to the provider and may delay transportation services.

Instructions To Complete The Statewide Provider Certification Form For Ambulatory And Wheelchair Transports

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