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The form provides various modes of transportation, including livery, ambulette (ambulatory and wheelchair), stretcher van, BLS ambulance, and ALS ambulance, catering to different patient needs.
Users must justify the chosen mode of transportation, ensuring that it aligns with the patient's medical requirements.
The form allows users to specify whether the transportation need is long-term or temporary, with an option to indicate the duration for temporary needs.
A certification statement is included, requiring the requester to acknowledge understanding of Medicaid rules and regulations related to travel orders.
The form must be completed by a physician or authorized entity, emphasizing the importance of medical oversight in transportation requests.
The form includes specific contact information for faxing submissions, ensuring proper processing by the New York State Department of Health.
It is mandated that the original form be maintained in the patient's medical record for future reference and compliance purposes.
