Rtp Bus Pass Appointment Verification Form
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1RTP Bus Pass Appointment Verification form
Name:____________________________________________
Bus Pass Month:_____________________
Step 1
HAVE YOUR APPOINTMENTS VERIFIED BY THE MEDICAL OFFICE
Medical Provider(s): By signing this form you are verifying to MaineCare that the above named client
was seen in your office during the month indicated, for a medical nature; signature/stamp as well
as date of appointment must be completed or rider will be denied a bus pass.
1st Appointment
___________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
2nd Appointment
___________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
3rd Appointment
___________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
STEP 2
CLIENT OR GUARDIAN SIGN AND DATE
Client: By signing this form you are certifying to MaineCare that you went to the three appointments
your medical provider(s) listed above, and that the three appointments listed below for next month
are correct.
_____________________________________________
_________________
(Client/Guardian Signature)
(date)
STEP 3
UPCOMING APPOINTMENTS FOR THE MONTH OF
_________________
Medical provider(s): Please list the upcoming appointments that the above named client has with you
for the month listed in step 3. By filling in this portion, you are certifying to MaineCare that the above
named client has this appointment scheduled. Please include provider name, phone number and
the date of the appointment(s).
These appointments must be for MaineCare eligible services.
1st Appointment
______________________________________________
_________________
Place of Business for Appointment
Appointment Time
______________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
2nd Appointment
______________________________________________
_________________
Place of Business for Appointment
Appointment Time
______________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
3rd Appointment
______________________________________________
_________________
Place of Business for Appointment
Appointment Time
______________________________________________
_________________
Provider Signature or Stamp
Phone Number
Date of Appointment
Client: If your Medical Provider does not complete step one and you received a pass the previous
month you will be denied the pass for this month. If Step 3 is not filled out you must have
appointment cards.
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