Pt 1 Form – Fill Out and Use This PDF

Instructions for Completing the Prescription for Transportation Form

Section 1 – Enter the member’s name, date of birth, MassHealth member ID, telephone number, and home address, including apartment number, if applicable.

In certain circumstances MassHealth may authorize a member to be picked up at an address other than his/ her home address. If the member is to be picked up at an alternate address, enter the alternate address information below the home address information. If there is a mailing address that is different from the home address, enter that below the alternate pick-up address.

Section 2 – Enter the provider’s name, telephone number, address, MassHealth provider ID and location code, and the NPI.

The provider requesting transportation should be a physician, physician’s assistant, nurse midwife, dentist, nurse practitioner, psychologist, or managed care representative, and an active MassHealth provider.

Section 3 – If the provider is also the treating provider, place a check mark in the box labeled “Check if same as provider listed in Section 2.” If the treating provider is different from the provider filling out Section 2, enter that provider’s name, telephone number, address, and, if it is known, their MassHealth provider ID and location code, and the NPI.

If the treatment destination is outside of the member’s locality (city or town of residence, or immediately adjacent communities), indicate why the medical care is unavailable to the member within the member’s locality.

Section 4 – Indicate the specific medical care that will be provided.

Section 5 – Indicate how many weeks or months the member will require transportation, and how frequently the member will be going per week or per month for the service. MassHealth will not authorize more than six months of transportation for an acute illness, or one year of transportation for a chronic illness. For a single visit, enter “1” week, and “1” visit per week.

Section 6 – Indicate if there is a medical reason that the member (or guardian, in accompanying the member) is unable to use public transportation. Provide the specific physical or mental disability that prevents the member from using public transportation.

Section 7 – Indicate if a wheelchair van or an escort is necessary.

Wheelchair van transportation may be provided for non-emergency medical services for members who use a wheelchair or whose severe mobility impairments prevent them from traveling in a vehicle other than a wheelchair van.

Section 8 – The signature of the physician, physician’s assistant, nurse midwife, dentist, nurse practitioner, psychologist, managed care representative, or dental third-party administrator is required to process the PT-1 form. The provider’s signature indicates that all information contained on the form is accurate to the best of his/her knowledge.

For more detailed information about the MassHealth transportation benefit, consult the MassHealth transportation regulations at 130 CMR 407.000. If you have any questions about completing this form, please call the MassHealth Transportation Authorization Unit at 1-800-841-2900.