Medical Transportation Forms
Below are the forms required for Medicaid Transportation. The Provider Certification Form (PCF) is required for every client, and the Distant Transport Form is required for every out of area referral. Frequency of forms may vary, contact our office for more information.
As of July 1, 2018 there is only one certification form for all mobility – ambulatory, wheelchair, and stretcher. For transfers or discharges from a facility, please use the separate Transfer & Discharge form.
- Medical Assistance Statewide Provider Certification Form (PCF) w/ Instruction Sheet
- Medical Assistance Statewide Transfer & Discharge Form w/ Instruction Sheet
- Medical Assistance Statewide Distant Transport & Referral Form
The bus ticket appointment verification form is to be completed by a medical provider, and used for clients who have three or more medical appointments per week. See form for further instructions. Clients who utilize our program for rides cannot get bus tickets – they must choose one or the other.