NEW FORM Non-Emergency Medical Transportation – Physician Certification Statement Form
| Date: | July 13, 2017 |
| To: | Health Plan of San Joaquin Providers, Practitioners and Facilities |
| From: | HPSJ Medical Management Department |
| Subject: | NEW FORM Non-Emergency Medical Transportation – Physician Certification Statement Form |
| Business: | Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM) |
Effective July 1, 2017
For non-emergency medical transportation (NEMT) services, providers will be required to complete the updated Physician Certification Statement form (attached).
This updated form replaces the Non-Emergency Medical Transportation (NEMT) Required Justification form previously in use.
- This new form is used for non-emergency medical transportation services, such as wheelchairs, gurney vans and ambulance transport.
- Attach this new form to prior authorization requests.
Should you have any questions, please contact our Customer Services Department at (209)942-6320.
Thank you for continuing to partner with Health Plan of San Joaquin on behalf of our members who are your patients.
Physician Certification Statement form below: