Form Odm 03452 - Certification Of Necessity For Transportation By Wheelchair Van
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1Ohio Department of Medicaid
CERTIFICATION OF NECESSITY
FOR TRANSPORTATION
BY WHEELCHAIR VAN
Individual Information
2. Ohio Medicaid Billing Number ― 12 Digits
1. Name
(Enter the full name of the individual transported.)
3. Address
(Enter the individual's home address. This information may be used to confirm the identity of the individual.)
Transportation Provider Information
4. Provider Name (
Enter the business name of the transportation provider.)
6. National Provider Identifier (NPI),
―
5. Ohio Medicaid Provider Number ― 7 Digits
10 Digits
If Applicable
Certification
8. Period Beginning Date (
7. Criteria
Enter the first date of the certification
period.)
By signing this document, the practitioner certifies that two
statements are true:
9. Length (
Mark one box to indicate the length of time for which
a. This individual must be accompanied by a mobility-
the individual is certified for transport. For certification on a
related assistive device from the point of pick-up to the
temporary basis, specify the number of calendar days, up to 90.
point of drop-off.
If no time period is indicated, then the certification is valid for
b. Transport of this individual by standard passenger
the Period Beginning Date only.)
vehicle or common carrier is precluded or
Not more than
day(s)
contraindicated.
One year
Additional Information Relevant to Certification
10. Comments or Explanations, If Necessary or Appropriate
Certifying Practitioner Information
11. Name of Practitioner (
Enter the full name of the certifying practitioner.)
12. Ohio Medicaid Provider Number,
― 7 Digits
13. National Provider Identifier (NPI) ― 10 Digits
If Applicable
Signature Information
14. Date of Signature
15. Name of Person Signing
16. Signature and Professional Designation (
Persons who, with proper authority or approval, sign on behalf of the certifying practitioner
must include the practitioner's name as well as their own signature and designation or job title.)
False certification constitutes Medicaid fraud.
This form confirms the certification of one individual for transport by one service provider; certification is not transferrable between
individuals or service providers. A photocopy, an electronic copy, or a facsimile transmittal of the completed, signed, and dated
certification form is as valid as the original for documentation purposes. Completion of this form is required in accordance with
Chapter 5160-15 of the Ohio Administrative Code.
ODM 03452 (Rev. 7/2015)
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Parent category: Medical