Distance Verification Form
Member’s referring or rendering healthcare provider must complete this form
Member’s Name:
D.O.B.:
Member’s Medicaid ID #:
Appt. Date:
Referring or Rendering Healthcare Provider:
Phone #:
You have referred and/or will be treating the above named Member at
healthcare provider or name of facility).
(name of
The Member named above is requesting transportation to a Department of Health and Human
Resources healthcare provider located outside of their covered service area. Members must
use the healthcare provider closest to their home that can accommodate their needs.
Please list reason why this Member cannot be treated by a healthcare provider closer to their
home:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide specific medical diagnosis:
______________________________________________________________________________
______________________________________________________________________________
Is this a one time authorization? ___________ Ongoing treatment? ____________
If ongoing treatment, please specify end date of approval ____________________
Referring/Rendering
Healthcare Provider’s Signature
Date
Referring/Rendering Healthcare Provider’s Address
Please complete and return this Distance Verification Form at least 3 business days prior to the
appointment.
Fax: 844-549-8346 Attn: Care Management
2 Hale Street Charleston, WV 25301
MTM cannot arrange transportation to the requested location until we review and process this document.
2 Hale Street
|
Charleston, WV 25301
|
681.245.8300
|
www.mtm-inc.net