Statewide Medical Assistance Provider Certification Form For Ambulatory And Wheelchair Transports

Somerset County Health Department

Medical Assistance Transportation Referral

Phone: (443) 523-1722

Fax: (410) 651-5680

STATEWIDE MEDICAL ASSISTANCE PROVIDER CERTIFICATION FORM FOR AMBULATORY AND WHEELCHAIR TRANSPORTS

PLEASE PRINT CLEARLY & COMPLETELY – FAILURE TO DO SO WILL RESULT IN DELAYS AS INCOMPLETE AND ILLEGIBLE FORMS MUST BE RETURNED

SECTION 1 - PATIENT PERSONAL INFORMATION:

Last Name:

First Name:

Address:

City/State/Zip:

Bldg or Facility

Room/Bed #

Patient Contact/Phone:

Name:

DOB:

Social Security Number:(Optional)

Medical Assistance

Medicare

Other

Number:

Number:

Insurance:

SECTION 2 - PATIENT MEDICAL INFORMATION:

Primary Diagnosis & Relevant Secondary Diagnosis(es):DO NOT enter ICD or DSM Codes

List Relevant Associated Symptoms:

Patient Weight

Patient Height

Adjunctive Information:

Oxygen

In Pounds:

In Feet & Inches:

Has

portable tank

Wheeled Cart

Shoulder Bag

own

Other relative conditions which may affect transport – check only those which apply:

Hearing Impaired

Visually Impaired

Cognitively Impaired

Behavioral or Mental Health Disability

SECTION 3 - PATIENT MEDICAL TRANSPORT INFORMATION: * ALL OUT OF AREA TRANSPORTS REQUIRE ADDITIONAL INFORMATION (SEE PAGE 2)

Type of Medical Service Patient is being Transported for: (List multiple if applicable)

Duration of Treatment:

Permanent

Temporary

If temporary, anticipated duration:

Frequency of Appointments:

Daily

Weekly - # Times per Week: _____________

Monthly - # Times per Month: _____________

Other: Specify: ________________

SECTION 4 - CERTIFIED MODE OF TRANSPORTATION:

1- I certify that this condition/illness causes a temporary or permanent medical need to such a degree that

it is medically necessary for the individual to be accompanied during transport.

Yes

No

Note: All minors must be accompanied by an adult parent or guardian; however, non-minors require medical necessity to be accompanied during transport.

2- I certify that this condition/illness causes a temporary or permanent medical need to such a degree that

it is impossible for the patient to use public/ADA/Paratransit transportation.

Yes

No

CHECK ONE:

AMBULATORY (Able to walk)

Enter Distance: __________________________

Ambulatory means the patient is able to ambulate independently or with assistance.

WHEELCHAIR

TRANSFERRABLE

“WHEELCHAIR” means the patient is able to travel in a wheelchair and the patient owns or

has access to a wheelchair. The Medical Assistance Transportation Office may not have

Indicate Type:

REGULAR/MANUAL

ELECTRIC

resources to provide wheelchairs and

SCOOTER

XWIDE (Bariatric)

SPECIALTY

DOES NOT have resources to return privately owned wheelchairs.

Indicate Access at Residence/Pick Up Facility: (if known)

“TRANSFERRABLE” means the patient is able to safely transfer from a wheelchair to a

RAMP OR

STEPS If steps, give number _________________

vehicle and safely exit the vehicle.

PROVIDER CERTIFICATION: To be completed ONLY by a Physician, Certified Nurse Practitioner (CRNP) or Dentist and must include Medical Assistance or NPI Number

By signing this form, you are certifying:

1.

The services described are medically necessary AND

2.

You understand that information provided is subject to investigation and verification. Misrepresentation or falsification of essential information which leads to inappropriate

payment may lead to sanctions and/or penalties under applicable Federal and/or State law.

3.

This form is valid for a period not to exceed one year from the date of signing.

Check Provider Type:

Physician

CRNP

Dentist

Signature

Date

Provider’s Medical

of Provider:

Signed:

Assistance Or NPI Number:

Printed Name

Printed Full

of Provider:

Address of

Provider:

Provider’s

Telephone Number: