Non-Emergency Medical Transportation Authorization Request 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFO section. Enter the patient's name, date of birth, age, and Medi-Cal number. Specify the preferred language for both spoken and understanding.
3. Complete the patient address details including city, zip code, and phone number. Indicate if the patient resides in a home, board and care facility, ICF-DD, SNF, or other.
4. In the PRESCRIPTION AND MEDICAL NECESSITY CRITERIA section, provide information about the prescribing physician and primary care physician. Ensure their NPI numbers and contact details are accurately filled.
5. Specify the date and time when NEMT is required along with the name and telephone number of the person accompanying the patient.
6. Mark any qualifying medical necessity criteria that apply to the member's condition. Attach relevant medical records to substantiate these claims.
7. Finally, ensure that all signatures are completed where necessary before submitting your request through our platform.

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