25 Mile Form | sunshinerides

Health First Colorado

Verification Form for transportation over 25 miles

The member’s medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way.

First name

Last name

Patient Health First Colorado ID

Member Date of Birth

Facility Name

Facility Address

Medical Provider Name and Title

Medicaid Program ID

Staff Contact Name and Title

Staff ID if applicable

Staff Contact Phone

Date(s) Verification is Valid for

Date(s) of Trip(s)

Medical Provider Attestation

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil, or both. I certify under penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the information provided is accurate to the best of my knowledge.

Signature

Date Signed

This form cannot be completed after the trip has been rendered. This trip must meet the requirements in 10CCR 2505-10 Section 8.014, Non-Emergent Medical Transportation.