Ensuring access to necessary medical services for individuals with significant mobility challenges is a critical aspect of healthcare management. The State of California—Health and Human Services Agency, through the Department of Health Care Services, provides a systematic approach to facilitate this via the NONEMERGENCY MEDICAL TRANSPORTATION (NEMT) REQUIRED JUSTIFICATION, better known as the DHCS 6182 form. This document serves as a comprehensive tool to justify and authorize the provision of non-emergency medical transport for individuals under the Medi-Cal program. It meticulously captures essential details, starting from the patient’s name and Medi-Cal ID number, through to specifics about the required transport, including the service dates, appointment times, and the patient’s mobility aids, like wheelchairs or canes. Furthermore, critical information regarding the medical necessity for the transportation is detailed, requiring a physician’s diagnosis, the purpose of the medical visit, and a detailed treatment plan including objectives and interventions. Significantly, this form stands as a prescription in itself, necessitating the personal signature of the authorizing physician, thereby ensuring that every nonemergency medical transportation request is backed by a thorough assessment of patient needs, underscoring the form's vital role in patient care coordination.
| Question | Answer |
|---|---|
| Form Name | Form Dhcs 6182 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dhcs_6182 nemt california form |
State of |
Department of Health Care Services |
NONEMERGENCY MEDICAL TRANSPORTATION (NEMT) REQUIRED JUSTIFICATION
In order to appropriately evaluate your request, complete all form fields below including physician signature and date of signature. If any field is incomplete, further documentation may be requested. This form constitutes a prescription. [References: California Code of Regulations (CCR), Title 22, Sections 51003, 51303, 51323 and the
1. Patient’s name
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3. The current Skilled Nursing Facility (SNF) face sheet is:
attached, since this patient currently resides in a SNF. not applicable, since this patient resides at home.
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Dates of Service (DOS) |
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5. Appointment time |
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From: _____________ |
To: _______________ |
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Start: _______ |
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End: _______ |
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Days(s) of the week transported to above appointment(s) |
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Monday |
Tuesday |
Wednesday |
Thursday |
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Friday |
Saturday |
Sunday |
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Documentation is attached |
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attached, since transport is not to the nearest facility that can meet the patient’s medical needs. |
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not applicable, as transport is to the nearest facility that can meet the patient’s medical needs.
8.Diagnosis specific to visit(s)
9.Medical purpose/justification for visit(s)
10. The prescribed treatment plan including problems, interventions, and goals (along with why original goals were not met, if this is a reauthorization TAR)
is attached, since request is for multiple transports that are ongoing to same provider for same chronic diagnosis.
is not applicable, since request is for a single transport for a routine visit or
11. Patient mobilizes via:
Wheelchair |
Walker |
Cane |
Other (describe): |
12.Functional limitations, (specific physical or mental), that preclude the patient’s ability to ambulate without assistance or to be transported by private or public conveyance: (If more space is needed, please attach another page.)
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Based on 11 and 12, above, the required mode of transport is: |
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Wheelchair van |
Gurney or litter van |
Ambulance |
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Physician signature (Physician’s personal signature only. No proxy. No stamps.) |
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Date |
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Physician specialty (print or type) |
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17. License number |
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Physician name (print or type) |
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Telephone number (Area code and number) |
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Physician address (number, street, city, zip code) |
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DHCS 6182 (rev. 9/09)