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Transportation Application
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Seniors & Disabled Transportation Application

Please complete the Transportation Application to get started as a Transportation Client for Complete Care:

Ambulette Certification of Medical Necessity

  
  

(Is this something that needs to be in the online form?)

A. Signature & Professional Letters (i.e. MD, DO, RN, APN, LSW)

B. Signature Date


Instructions for the 03452 Ambulette Certification of Medical Neccesity:

1. Patient's Name - Enter the name of the patient being transported.
2. Patient's Address - Enter teh address of the patient being transported. 
3. Patient's Medicaid Billing Number - Enter the patient's Medicaid billing number as it appears on their Ohio Medicaid Card
4. Ambulette Provider - Enter the name of the provider of Ambulette service(s.)
5. Ambulette Provider Number - Enter the seven digit Medicaid number of the provider of Ambulette service(s.)
6. Date(s) of (First) Transport - Enter the first date of transport, date of transport or range of dates of transport as applicable.
7. Why must the patient use an Ambulette instead of other types of transport? - Place a check mark in all applicable reason(s) why the patient cannot use other types of tranpsort and must use an Ambulette. Important Note: If the patient does not meet the definition of Non-Ambulatory, he or she should be referred to the County Department of JOb and Family Services to apply for Enhanced Medical Transportation services in accordance with chapter 5101:3-24 of the Administrative Code.
8. What medical condition requires the the patient to use an Ambulette? Describe the patient's medical condition that precludes this patient from using other transport and certifies that using an Ambulette is medically necessary. The description should be in terms that na average person could understand. An ICD-9 code and its description may be included as part of the response. The description of the medical condition should support the reason indicated in number 7.
9. How long may the patient require an Ambulette for transportation? - Indicate whether the patient requires an Ambulette ofr transportation on a temporary or permanent basis by placing a check mark in the appropriate box. If temporary, enter the number of days from the date of first transport that the patient is expected to need an Ambulette in the box provided. If the length of time exceeds 90 days a new certification form must be obtained. 
10. Are there any other comments or explanations? (Optional) - Area to be used as needed to make additional comments or notations. For example, a provider may use this area to document the need and use of additional attendants. In addition, the area may be used to document the reason for transport to a destination outside the patients community (a fifty mile radius from patient's residence) or to explain excessive mileage or an unusual desination that was prior authorized.
11. Who is the attending practitioner (Medicaid Provider) that has ordered the Ambulette transport?
A. Attending Practitioner - Please print the name of the attending practitioner who is ordering this medical transport
B. Attending Practitioner Provider Number (Do not use 9111115) - Enter the seven digit Medicaid Provider Number of the attending practitioner who is ordering the medical transport
12. Who is the attending practitioner or R.N./dishcarge planner that is signing?
A. Practitioner's Signature & Initials (i.e. MD, DO, RN, APN, LSW) - An original signature of the attending practitioner (M.D., D.O., D.P.M., L.W.S., OR A.P.N. who holds a Certificate of Authority or a Notice of Approval is required. A registered nurse or a discharge planner, with the consent of the attending practitioner, may write the practitioner's name on the signature line and sign his or her own first name, last name, and nursing skill level (if applicable) after the practitioner's name. A discharge planner must be employed by the hospital where the patient is being treated and from which the patient is transported in order to complete this section as specified above. In addition, the discharge planner must be a social worker who is practicing within their scope of practice in accordance with chapter 4757 of the Administrative Code.
B. Signature Date - The date the attending practitioner signed the form.

Note: This form is non-transferable between Ambulette providers.

This form is required as a certification of medical necessity of transport to medicaid-covered services in accordance with chapter 5101:3-15 of the Administrative Code.
ODM 03452 (7/2014)
Formerly JFS 03452