Attendant Medical Necessity Form - MTM Inc
Medically Necessary Attendant Form
Beneficiary’s healthcare provider must complete this form
Beneficiary’s name: D.O.B.:
Beneficiary’s Medicaid ID number: Appt. date(s):
Healthcare provider’s name: Phone #:
Medical Transportation Management (MTM) provides Non-Emergency Medical Transportation to Mississippi Medicaid Beneficiaries in your area. The above named Beneficiary is requesting an attendant to accompany them to their medical appointment(s). An attendant may escort a Beneficiary with physical, developmental, or cognitive disabilities.
Please check the appropriate box (es) below to indicate the Beneficiary’s current need:
Beneficiary requires assistance during transportation due to a physical disability.
Beneficiary requires supervision while being transported due to a developmental disability.
Beneficiary requires supervision while being transported due to a cognitive issue.
Healthcare provider’s signature Date
Healthcare provider’s credential (MD, RN) Healthcare provider’s address
DOM Provider ID number (required)
Please complete and return this form via fax or mail to:
Fax: 866-813-0138 Attn: MTM Care Management
6360 I-55 N, Suite 201 Jackson, MS 39211
MTM cannot arrange transportation with an attendant until we review and process this document. Thank you for your assistance.
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MS NET Services for ESRD
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