Medicaid Transportation Reimbusment Form printable pdf download

Medicaid Transportation Reimbusment Form

For Month of

,20

Prior Authorization by:

Client Name:

Medicaid #:

Date:

Client Address:

Date of Birth:

PAR Date Range:

from

City, State, Zip

Units/ miles of service total:

Client Phone #

Name - Head of Household:

Relationship to Medicaid Client:

Transportation Provider

Address, Phone

Oxygen

Signature of Provider:

PAR Date Span, units, and days authorized:

Special Request or Need

Client's Signature

To Be Completed By Medical Provider

Appt

Number

Medicaid provided

Signature of medical provider & date of

Trip Origination Address

Destination

Date

Time

of miles

service? Yes / No

service

Submit Your Form

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us via email at or call 1-844-686-7433 for your link. Fax : 970-468-1208

Mail : PO Box 2308, Silverthorne, CO 80498

Mountain Ride One-Call / One-Click Transportation Resource Center 1-844-686-7433

Medicaid Transportation Reimbusment Form

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