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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