Healthcare Provider Statement of Medical Need Healthcare Provider: Please the appropriate section(s) that apply to your Clients’ needs to ensure that the Managed Transportation Organization (MTO) provides Non-Emergency Medical Transportation (NEMT) that is appropriate for your patient’s medical condition and/or is medically necessary. Client Information: Client Name: Date of Birth: Medicaid ID: Medicaid Service Diagnosis Code: A. Attendant Services: Section Client requires an attendant during transport Adult younger than 14 years of age requires both Parents/Legal Guardian during out-patient visits Child or in- patient stay Justification:__________________________________________________________________________ B. Transportation Mode: (Indicate whether the Client’s medical condition prohibits use of): Section Transit Mass Para-transit Ride (more than one passenger in the vehicle during transport) Shared Air Commercial Please Specify: ______________________________________________________________ Other – C. Inpatient Services: Section Facility Name: Address: Admission Date: Projected Discharge Date: D. Distance Travel: (Supporting documentation may be required) Section services are not available within the State of Texas Required services are not available in the county or adjacent county of residence Required Justification:__________________________________________________________________________ Facility Information: Name: Phone: Address: Receiving Physician: NPI: Name: Phone: Address:
Healthcare Provider Statement of Medical Need Healthcare Provider: Please the appropriate section(s) that apply to your Clients’ needs to ensure that the Managed Transportation Organization (MTO) provides Non-Emergency Medical Transportation (NEMT) that is appropriate for your patient’s medical condition and/or is medically necessary. Client Information: Client Name: Date of Birth: Medicaid ID: Medicaid Service Diagnosis Code: Section A. Attendant Services: Adult Client requires an attendant during transport Child younger than 14 years of age requires both Parents/Legal Guardian during out-patient visits or in- patient stay Justification:__________________________________________________________________________ Section B. Transportation Mode: (Indicate whether the Client’s medical condition prohibits use of): Mass Transit Para-transit Shared Ride (more than one passenger in the vehicle during transport) Commercial Air Other – Please Specify: ______________________________________________________________ Section C. Inpatient Services: Facility Name: Address: Admission Date: Projected Discharge Date: Section D. Distance Travel: (Supporting documentation may be required) Required services are not available within the State of Texas Required services are not available in the county or adjacent county of residence Justification:__________________________________________________________________________ Facility Information: Name: Phone: Address: Receiving Physician: NPI: Name: Phone: Address:
TX-Healthcare-Provider-Statement-of-Medical-Need.docx