Medicaid transportation form 2015-2026

1. Click ‘Get Form’ to open the Medicaid Transportation Justification Request in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
3. Fill in the Medicaid number and address, ensuring all information is accurate for processing.
4. Select the medically necessary mode of transportation by checking one of the options provided, such as Livery or BLS Ambulance.
5. In the justification section, clearly explain why the selected mode of transport is necessary for the patient’s needs.
6. Indicate whether this transportation need is long-term or temporary, and if temporary, specify how many months it will be required.
7. Complete the certification statement by having a physician print their name, sign, and provide their NPI number along with contact details.
8. Finally, fax the completed form to the appropriate number based on your location as indicated at the bottom of the document.

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