Are you looking for a guide to filling out Form DHCS 6182? From understanding the form and what's being asked of you to ensuring your information is correct, this blog post will provide all the guidance you need when completing this important document. It can be intimidating or confusing trying to figure out forms like these, but with our help, we'll make sure you have everything in order and ready to go before submitting.
| 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
2.
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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pm |
End: _______ |
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pm |
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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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14. |
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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18. |
Physician name (print or type) |
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19. |
Telephone number (Area code and number) |
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20. |
Physician address (number, street, city, zip code) |
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DHCS 6182 (rev. 9/09)