Attendant Medical Necessity Form - MTM Inc



Medically Necessary Attendant Form

Please print or type information below and complete form in its entirety

MTM is providing transportation to the MHCP member listed below. They have requested an additional passenger accompany them to their non-emergency medical appointment. Please provide an explanation as to why it is medically necessary for an additional passenger(s) to assist the member.

Patient Name:       DOB:       MA #:      

1. Diagnosis(s) for which you are treating member: ___________________________________________

_____________________________________________________________________________________

2. Medical reason why additional passenger(s) is needed to accompany member:

______________________________________________________________________________

3.What assistance does the passenger provide: ____________

______________________________________________________________________________

_____________________________________________________________________________________

X________________________________ ________________ _________________________

Medical Provider Signature Date Contact #

_________________________________ ________________ __________________________

Medical Provider Name (printed) Provider License # Facility Name

Medical Transportation Management, Inc. (MTM) arranges non-emergency transportation services to medically necessary appointments for patients who qualify under Minnesota Healthcare Program (MHCP). Minnesota Non Emergency Transportation (MNet) operated by MTM, is required by the Department of Human Services (DHS) to verify MHCP patients receive medical services from the closest and most appropriate provider. MNet has a Business Associates Agreement with the State of Minnesota and therefore is covered under HIPAA rules and regulations.

Upon completion please return form with cover sheet to:

MNET’s Care Management Department

Fax number: (651) 203-1262

Email: mnetcaremanagement@mtm-

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