The Medicaid Standing Order Form has been updated as of January 1, 2017. This new form is now available on the HCSC website. The goal of this form is to provide a standardized process for ordering medical items and supplies for all Medicaid recipients statewide. The new form is also designed to improve communication and coordination between health care providers and pharmacies. It is important to note that the use of this form does not replace any other standing orders currently in place. Only health care providers who are authorized by the Department of Health Services may use this form. For more information, please visit the HCSC website.
Below is the information concerning the form you were looking for to fill out. It will show you the time it takes to fill out medicaid standing order, exactly what parts you will need to fill in and several additional specific details.
Question | Answer |
---|---|
Form Name | Medicaid Standing Order |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | 2015 form request for transportation, medicaid transportation form 2020, mas transportation form, medicaid transportation form online |
Form
Medicaid Transportation Standing Order Request Form for Regularly Reoccurring Appointments
3 or more times per week for 3 or more months’ duration
Questions? Contact LogistiCare Facility Services Dept.:
Enrollee’s Name: ____________________________ DOB:
Appointment Days: ( ) Sunday ( ) Monday ( ) Tuesday ( ) Wednesday ( |
) Thursday ( |
) Friday ( ) Saturday |
Start date __________ Emergency Contact: ____________________ Relationship to Patient: |
________ Phone: ( |
) |
Medically necessary mode of transportation:
Livery: Enrollee can walk to the curb and board and exit the vehicle unassisted, but cannot utilize the bus or subway.
Ambulette Ambulatory: Enrollee can walk but requires driver assistance from residence to the medical appointment.
Ambulette Wheelchair: Enrollee is wheelchair user, requires a
Stretcher Van: Enrollee is confined to bed, cannot sit in a wheelchair, and does not require medical attention/monitoring during transport.
BLS Ambulance: Enrollee is confined to bed, cannot sit in a wheelchair, and requires medical attention/monitoring during transport for reasons such as isolation precautions, oxygen not
Preferred Transportation Provider: _____________________________________________ Phone ( )
Pick Up: Check if it’s the person’s home ( ) or a facility ( ). If a facility, please name it: ________________________________
Pick up street address: ________________________________________________________ Bldg: _________ Apt: __________
City: _________________________ State: ______ Zip: __________ Phone: ( )
Directions: ______________________________________________________________________________________________
Appointment Time: ________ AM / PM Suggested Pick Up Time from Home: ________ AM / PM
_______________________________________________________________________________________________________
Drop Off Information:
Drop Off At (Facility Name): _______________________________ Contact Name: ____________________________________
Street address: ______________________________________________________________ Bldg: _________ Apt: __________
City: _________________________ State: ______ Zip: __________ Phone: ( )
Return Pick Up Time: ________ AM / PM
CERTIFICATION STATEMENT: I (or the entity making the request) understand that orders for
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_____________________ |
__________ |
____________________ |
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Physician's Name (PRINT) |
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NPI# |
Date |
Telephone # |
_______________________________________________ |
_____________________________________________________ |
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Name of the medical practice, hospital or clinic |
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Medical Practitioner's Address |
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________________________________________ |
_____________________________ |
____________________ |
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Indicate name of nurse/social worker or other person who |
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Title |
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Telephone # |
assisted in completing this form |
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Physician’s signature ______________________________________________________________________________________
Fax to: