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2022-10 CalOptima Health-Referral Request Transportation Services And Physician Certification Statem-2026
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How to use or fill out 2022-10 CalOptima Health-Referral Request Transportation Services And Physician Certification Statem
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- Click ‘Get Form’ to open it in the editor.
- 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).
- Next, complete the Prescribing Provider Information. Input the provider’s full name, phone number, NPI, facility name, and contact details.
- 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.
- Justify the need for transportation by detailing medical documentation that supports physical limitations. Include diagnosis and ICD-10 codes as necessary.
- Finally, ensure that a qualified professional signs the Certification Statement section to validate medical necessity.
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The HCA Advisory Board consists of leaders in the health and university community, alumni, and/or faculty,
Medi-Cal plan can help you with referrals and coordination, again, for transportation to medical appointments.