Southeastrans Transportation Management Request Form
This file provides comprehensive instructions and details for submitting a standing order request to Southeastrans. It includes necessary information for eligibility verification and transport services. Use this form to ensure timely processing of transportation requests.
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How do I fill this out?
To fill out this form, start by gathering all necessary personal and treatment information. Make sure to complete each section accurately and double-check your entries for any errors. Once all fields are completed, submit the form within the specified timeframe.
How to fill out the Southeastrans Transportation Management Request Form?
1
Gather required information such as member details and treatment schedule.
2
Complete each section of the form by filling in all necessary fields.
3
Double-check for accuracy to avoid any submission issues.
4
Submit the completed form to Southeastrans within 5 business days.
5
Maintain a copy for your records.
Who needs the Southeastrans Transportation Management Request Form?
1
Patients requiring transportation for medical appointments.
2
Healthcare providers scheduling transport on behalf of patients.
3
Caregivers managing logistics for patients with mobility challenges.
4
Facilities coordinating routine transports for treatment.
5
Members needing assistance to navigate transportation options.
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What are the instructions for submitting this form?
To submit this form, complete it in full and return it to Southeastrans within 5 business days. You can either fax it to 404-581-5543 or reach out via phone at 1-844-856-7908 for assistance. Make sure to keep a copy for your records and notify Southeastrans of any changes to your requested transport details.
What are the important dates for this form in 2024 and 2025?
Ensure you submit the standing order request within 5 business days of the initial transport. Regular recertification is required every 6 months for dialysis standing orders and every 3 months for other treatments in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to facilitate the transport management process for patients needing medical transportation. It serves as an official request for services, ensuring that all necessary information for eligibility verification is collected. Completing this form accurately is crucial for avoiding delays in transport services.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: The name of the individual requiring transportation.
- 2. Member's Complete Address: The full address of the member to schedule pick-up.
- 3. Member's Phone: Contact number for the member.
- 4. Emergency Contact: Information for an emergency contact person.
- 5. DOB: Date of birth of the member.
- 6. Gender: Gender of the individual (Male or Female).
- 7. CPT Code: Code for the specific services requested.
- 8. Medicaid ID #: Identification number assigned by Medicaid.
- 9. Duration of Treatment: Expected duration for the treatment.
- 10. Treatment Phone #: Contact number for the treatment facility.
What happens if I fail to submit this form?
Failing to submit this form can lead to delayed transportation services or loss of eligibility for required transport. It is crucial to adhere to submission deadlines to ensure continuous care.
- Service Delays: Without timely submission, transportation might be postponed.
- Cancellation of Services: Your standing order may be canceled if not recertified on schedule.
- Ineligibility for Transport: Failure to submit may result in ineligibility for Medicaid transportation.
How do I know when to use this form?
- 1. Routine Medical Visits: For consistent appointments such as dialysis or therapy.
- 2. Special Treatments: To arrange transport for specific medical procedures.
- 3. Emergency Situations: To secure urgent transportation for critical care.
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