The patient's medical provider completes this form indicating the most medically appropriate mode(s) of transportation the patient is eligible to receive under Non-Emergency Medical Transportation (NEMT). If the form has not been completed or has expired, the medical provider or the medical provider's approved staff must complete this form and submit to Veyo via fax, email, or by online form. For any ambulance mode of transportation, this form must be completed and submitted online at medicaidco.com, emailed, faxed or mailed to Veyo. PLEASE NOTE: This document cannot be completed by a non-emergency transportation provider.
Does the member have a medical condition or disability that prevents them from utilizing public transportation?
Please provide details of condition or disability that prevents the patient from utilizing public transportation.
Is the Patient currently registered through the local Access-A-Ride, Greeley-Evans Transit, Transfort, or similar ADA Paratransit system?
Is the patient able to get into and out of a regular sedan style vehicle? This includes patients who use a cane, walker, or transfer wheelchair, but are able to step into a regular car and do not require a lift.
Is the patient wheelchair bound and has their own wheelchair for transport?
This service cannot be selected solely for lifting needs without having an additional medical necessity present.
Wheel base of the patient's wheelchair?
Approximate weight of the wheelchair?
I affirm that the above statements are true and accurate to the best of my knowledge and federal funds will be used for the service I am requesting on behalf of my patient and the most medically appropriate service is being requested.
This form has changed and is no longer required to expire after 6 months.