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

Month

Day

Year

Facility Name

Facility Street Address Line 1

Facility Street Address Line 2

Facility City

Facility Zip Code

Treating Provider Name and Title

Treating Provider ID or NPI

This must be the provider ID, NOT the Member ID

Authorizing Contact Name and Title

Authorizing Contact Phone

Format 303-444-5555

Phone Extension if applicable

First date of treatment for this 90-day authorization period

Enter the first date of scheduled treatment for this 90 day authorization period in the format MM/DD/YYYY.

Optional notes

If there are any special instructions or information please type them here.

Select Reason

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

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This trip must meet the requirements in 10CCR 2505-10 Section 8.014, Non-Emergent Medical Transportation.