Medical Certificate of Transportation

To be valid, the Attending physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professional must complete and sign this certification. The least costly and most appropriate means of travel must be utilized.

Patient Name *

First

Last

Patient Date of Birth *

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Medicaid # *

Patient Contact Phone *

PLEASE CHECK ALL MEDICAL CONDITIONS BELOW THAT APPLY TO THIS PATIENT:

Unable to travel alone, needs service attendant
Requires Oxygen that is self-administered
Pediatric Patient
Traveling with an ADA service animal
Bariatric Patient

Note: If Bariatric please indicate Weight and Height below.

Bariatric Patients Only

Weight/Height

PLEASE SELECT WITCH MODE(S) OF TRANSPORATION THE PATIENT NEEDS:

Mileage Reimbursement

Does the patient own a Vehicle or have a friend, family member, Does patient not own a Vehicle or have a friend, family member, or volunteer who is willing to drive them to and from their medical or volunteer who is willing to take them to appointments? Is appointments?

Privately contracted vehicle / Taxi Service

Does patient not own a Vehicle or have a friend, family member, or volunteer who is willing to take them to appointments? Is the patient able to get into and out of the regular sedan style vehicle?

Non-Emergency Service

Non-Emergency Ambulance Service

This service cannot be selected solely for lifting needs without having any additional medical necessity present. Please check all that apply.

Potentially combative-dementia of behavioral
IV fluid administration and monitoring
Medication administration en-route
Advanced airway management including suctioning or vents
Oxygen administration by medical personnel
Medical supervision during transport

Name of licensed Medical Provider *

First

Last

Date Signed *

Phone number of Provider *

Provider Email *

Certification expiration date -OR- Expiry Date “INDEFINITE” *

I affirm that the above statements are true and accurate to the best of my knowledge and federal funds will be used for the service I am requesting on behalf of my patient and the most medically appropriate service is being requested.

Signature of licensed Medical Provider *

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