Medride 25 mile form. Medical Transportation Request Declaration form signed by you If you require care outside of Pueblo County the Medical Certificate of Transportation Services beyond 25 Miles form must also be completed. All NEMT forms and instructions can be found on the Provider Forms page under Claim Forms and Attachments. NEMT transportation consists of rides to and from covered medical appointments or services. Without this form completed, we are unable to provide rides to and from your long distance medical appointments. Medical Certificate of Transportation Services Beyond 25 Miles To be valid, the Attending Physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professionals must fully complete and sign this certification form. Medical Certification for Transportation Services Beyond 25 Miles The member's medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way. Medical certification of transportation services beyond 25 miles. New member welcome letter NEMT services member brochure (English) NEMT services member brochure (Spanish) Trip reservation form Standing order trip form Self-service portal release form Travel reimbursement process and overview (English) Download the following file and fill it Download PDF Failed to load PDF file. Fax it back to us: 720-615-8666. For shared rides, you may be asked to be ready earlier than expected. This trip must meet the requirements in 10CCR 2505-10 Section 8. When you call us for a ride, we will give you the timeframe you should be ready to be picked up by. Verification form for transportation services more than 25 miles The member’s medical provider must complete this form to verify the medical necessity of trips that exceed 25 miles, one way. 014, Non-Emergent Medical Transportation. Member’s medical provider must complete the Verification Form for Transportation Services More Than 25 Miles to verify the medical necessity of trip requests that exceed 25 miles, one way. Schedule a Ride Form: Request for transportation service Consent and Liability Release: Transportation Permission Form for age 13 and younger than 18 years old Escort Requirement: who may classify as an escort to accompany a client Eligibility Verification Form For Office Use ONLY: Consent and Liability Release: Transportation We have received a request for non-emergency medical transportation (NEMT) for one of your patients that exceeds 25 miles one way. Health First Colorado Verification Form for Long Distance NEMT transportation The member’s medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way, or 62. This form is valid for 90 days per member for regular trips to treatment locations. If a client lives beyond 25 miles from the Medical Provider then the additional 25 mile form must be filled out, which is found within the initial paperwork below. The Doctor’s Name & Address, as well as a good Telephone Number for confirmation of your medical appointment The Date & Time of your scheduled medical appointment or service If your destination is over 25 miles from your pickup location, the state of Colorado also requires you to fill out their 25+ Miles Form per appointment location. A— For appointments 25 miles or beyond from your pick up point, Health First Colorado Medicaid has implemented a state required form to be filled out by your medical provider’s office. 5 miles in applicable counties. All travel beyond 25 miles, will require the Beyond 25 mile authorization form which can be found below. Verification Form for Non-Emergent Medical Transportation (NEMT) Services more than 25 miles Health First Colorado Verification Form for Long Distance NEMT transportation The member’s medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way, or 62. New member welcome letter NEMT services member brochure (English) NEMT services member brochure (Spanish) Trip reservation form Standing order trip form Self-service portal release form Travel reimbursement process and overview (English) MedRide is a non-emergency medical transportation (NEMT) company based in Colorado. Effective May 1, 2024, the member’s referring or treating provider must complete the Verification Form for Transportation Services More Than 25 Miles, located on the Provider Forms web page under the Claim Forms and Attachments drop-down, to verify the medical necessity of trip requests that exceed 25 miles, one way. IntelliRide by transdev IntelliRide by transdev Medical Certificate of Transportation Services Beyond 25 Miles To be valid, the Attending Physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professionals must fully complete and sign this certification form. lokc, gxq5az, 6cls, x3e5d, smury, fnlu6a, xbzrig, ofu1, ahvdv, h2121,