30 60 form 2025

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60 votes

The document is a Transportation 30/60 Exception Request Form used to request transportation for members beyond state guidelines. It requires details such as member information, primary care doctor, diagnosis codes, and the clinic being referred to. Medical records supporting the necessity of travel must be attached. The completed form should be submitted via fax or email for eligibility review, and incomplete forms will be returned.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (60 Votes)

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