Medical Certificate Of Transportation Services (Mcts)

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Medical Certificate of Transportation Services (MCTS)
The patient’s medical provider completes this form indicating the most medically appropriate mode(s) of transportation the patient is
eligible to receive under Non-Emergency Medical Transportation (NEMT). If the form has not been completed or has expired, the medical
provider or the medical provider’s approved staff must complete this form and submit it to Veyo via fax, email or via online form. For any
ambulance mode of transportation, this form must be completed and submitted online at , emailed, faxed, or
mailed to Veyo.
This document cannot be completed by a non-emergency transportation provider
Patient Name:
Patient Date of Birth:
Patient Medicaid Number:
Please check all medical conditions below that apply to this patient:
 Requires Oxygen that is self-administered
 Bariatric patient - Weight _________ Height ________
 Traveling with ADA service animal
 Pediatric patient
Please check one:
1) Does member have access to a vehicle? □ Yes □ No
a) If No, please check the Public Transportation □
b) If Yes, please check the Mileage Reimbursement □
2) Does member have a medical condition or disability that prevents them from taking public transportation? □ Yes □ No
a) If Yes, please provide details of condition or disability that prevents them from utilizing public transportation.
 ADA Paratransit
 Ambulatory
Is the patient currently registered through the local Access-A-
Is the patient able to get into and out of a regular sedan style
Ride, Greeley Evans Transit, Transfort, or similar ADA Paratransit
vehicle? This includes patients who use a cane, walker, transfer
wheelchair but are able to step into a regular car and do not require
a lift.
 Wheelchair Van Service
 Non-Emergency Ambulance Service
Is this patient wheelchair bound and has their own wheelchair
□ Basic Life Support (BLS)
□ Advanced Lift Support (ALS)
Wheel base of the patient's wheelchair?
Approximate weight of the wheelchair?
Please explain medical condition requiring BLS/ALS transport.
I affirm that the above statements are true and accurate to the best of my knowledge and federal funds will be used for the service I
am requesting on behalf of my patient and the most medically appropriate service is being requested.
Name of Licensed medical provider:
Signature of medical facility staff:
Phone number of medical provider:
Expiry Date:
Or Expiry Date Indefinite □
This form has changed and is no longer required to expire after 6 months.
Veyo Phone: 855-264-6368 | Email: | Fax: 720-282-4450


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Parent category: Medical