30 60 form 2026

1. Click ‘Get Form’ to open the 30 60 Exception Request Form in the editor.
2. Begin by entering your Member ID and Member Name in the designated fields. Ensure that all personal information is accurate.
3. Fill in your Date of Birth and Date of Transportation. These dates are crucial for processing your request.
4. Provide the name of your Primary Care Doctor along with their signature and date. This confirms that they are aware of the referral.
5. Enter the Primary Care Clinic Name and include a detailed explanation, including diagnosis code(s), justifying why you need transportation beyond state guidelines.
6. Specify the Name and Address of the Clinic/Facility you are being referred to, along with the Date Span of Referral.
7. Attach any necessary medical records that support your request for transportation. Incomplete forms will be returned, so double-check all entries before submission.
8. Once completed, return this form via fax or email as indicated at the bottom of the document.

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