Non-Emergency Medical Transportation (NEMT) Authorization Request
Routine: Fax to 714-338-3153 Retrospective: Fax to 714-338-3153 Urgent: Fax to 714-571-2424
MEMBER INFO
Patient Name: ________________________________ F M Date of Birth: _______________ Age: _________
Medi-Cal Number (CIN): _______________ Preferred language: Spoken: ______________Understands: ___________
Patient Address: ________________________________ City: _______________ ZIP: _______ Phone: ____________
Home Board and Care ICF-DD SNF Other: _______________________________________
Facility Name: __________________________________________ Contact: _________________________________
Facility Contact Direct Telephone Number: ___________________ Fax Number: ____________________
Primary Dx: _________________________________ ICD-10: ______________
PRESCRIPTION AND MEDICAL NECESSITY CRITERIA (Rx must be completed, signed and dated by
attending physician)
Prescribing Physician: ____________________________
NPI # _________________________________________
Phone: ________________ FAX: ___________________
Address: _______________________________________
Primary Care Physician (PCP): _____________________
NPI # _________________________________________
Phone: ________________ FAX: ___________________
Address: _______________________________________
NEMT required to receive medical services on: Date: _____________________ Time: __________________
With: Name: _____________________________________________ Telephone Number: ___________________
Approximate duration of NEMT need: _________ Patient’s current NEMT Provider: _____________________
Ambulance, air ambulance, litter/gurney van and wheelchair van medical transportation services are covered
when the member’s medical and physical condition is such that transport by ordinary means of public or private
conveyance is medically contraindicated, and transportation is required for purposes of obtaining needed medical
care. Diagnosis alone does not constitute medical necessity.
Please mark member’s qualifying medical necessity criteria:** Attach medical records to substantiate medical necessity**
Ambulance: Member’s medical condition contraindicates the use of other forms of medical transportation. (Member
requires specialized equipment and/or personnel.) State functional limitations: ______________________________
Litter/gurney van: Member must be transported in a prone or supine position because member is incapable of sitting
for the period of time needed to transport. State functional limitations: _____________________________________
Wheelchair van: Member must be transported by wheelchair because of a disabling physical or mental limitation
and is unable to self-transfer or self-propel. State functional limitations: ____________________________________
Air ambulance: Member’s medical condition or practical considerations render ground transportation not feasible.
State functional limitations: _______________________________________________________________________
PHYSICIAN CERTIFICATION OF MEDICAL NECESSITY: California Code of Regulations [CCR], Title 22,
Section 51323 was used as criteria to determine medical necessity for the type of transportation requested.
M. D. / D. O. / D. D. S. Signature: __________________________________________ Date: _________________
Revised 7-31-17
