Non-Emergency Medical Transportation (NEMT) for Health Home Services REQUEST FORM

Date: 	

TO NEMT Broker:	FAX #:   	

NEMT Broker Look-up: http://www.hca.wa.gov/medicaid/transportation/pages/phone.aspx

FROM (Care Coordination Organization):  	

Name of Care Coordinator:		Phone #  	

Health Home Lead Agency:  (Check one)

 	Community Choice Healthcare

 	Northwest Regional Council

 	Community Health Plan of Washington		Optum Health

 	Coordinated Care Corporation
 	Molina Healthcare

 	SE WA Aging and Long Term Care
 	United Healthcare

Section I - Client Information

Last Name	First Name 	

ProviderOne ID Number	DOB: 	

Transportation Date (mm/dd/yyyy) and *Appointment Time: 	

Pick-up Address (exact address/entrance) and *Time: 	

Drop-off Address (exact address/entrance) and *Time: 	

Special Needs (e.g. escort; oxygen, wheelchair/oversize wheelchair; etc.):  	

Section II – Certification:

 		Client is Medicaid Eligible	Client is enrolled with the Health Home Lead selected above
 		Client needs transportation to an alternate location to receive health home services

Care Coordinator Signature/Date:	/