2022-10 CalOptima Health-Referral Request Transportation Services And Physician Certification Statem-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's first name, last name, date of birth, and Medi-Cal number. Select the appropriate living situation (Home, Board and Care, ICF-DD).
3. Next, complete the Prescribing Provider Information. Input the provider’s full name, phone number, NPI, facility name, and contact details.
4. In the NEMT section, choose the vehicle type required for transportation (Ambulance, Wheelchair Van, etc.) and provide the anticipated duration along with start and end dates.
5. Justify the need for transportation by detailing medical documentation that supports physical limitations. Include diagnosis and ICD-10 codes as necessary.
6. Finally, ensure that a qualified professional signs the Certification Statement section to validate medical necessity.

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