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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.

Member Date of Birth

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.

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.

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