Distance verification 2026

1. Click ‘Get Form’ to open the Distance Verification Form in the editor.
2. Begin by entering the Beneficiary's Name, Medicaid ID Number, and Date of Birth in the designated fields.
3. Fill in the Appointment Date and details of the Referring Provider, including their Name, DOM ID Number, and Phone Number.
4. The Referring Provider must sign and date the form. Ensure all information is accurate before proceeding.
5. In the section provided, explain why the Beneficiary cannot be treated by a closer healthcare provider.
6. Provide specific medical diagnosis along with ICD-10 code(s) as required.
7. Indicate whether this is a one-time authorization or ongoing treatment by checking the appropriate box.
8. If ongoing, specify an end date for approval (maximum of 12 months).
9. Complete the Healthcare Provider's information including Name, DOM ID Number, Address, Phone Number, and Fax Number.
10. Finally, review all entries for accuracy and completeness before submitting. Return this form at least three business days prior to the appointment.

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