Prior Authorization Form Non-Emergency Medical Transportation- Physician Certification Statement
A physician, dentist, podiatrist or mental health or substance use disorder provider responsible for providing care for a patient is responsible for determining medical necessity for non-emergency medical transportation services.
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The Prior Authorization Form Non-Emergency Medical Transportation – Physician Certification Statement app may be completed and signed by the patient’s physician, dentist, podiatrist or mental health or substance use disorder provider responsible for providing care for the patient to request non-emergency medical transportation for medical appointments. The physician is required to document and provide specific physical and medical limitations that preclude the patient’s ability to reasonably ambulate without assistance or be transported by public or private vehicles. The authorization request must be submitted prior to the appointment time.
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