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Standing Order Request Form for Regions 1, 7, 10 and 11 MTO
Form for medical practitioners to request regularly reoccurring (three or more times per week, for 3 or more months duration) reservations for transport to a Medicaid covered service in regions MTO 1, 7, 10 and 11
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Standing Order Request Form for Region 8 MTO
Form for medical practitioners to request regularly reoccurring (three or more times per week, for 3 or more months duration) reservations for transport to a Medicaid covered service in region 8 MTO
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Parental Authorization Form - Spanish
Authorization for a minor to travel with a different adult then parent/guardian
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Parental Authorization Form
Authorization for a minor to travel with a different adult then parent/guardian
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Minor Consent Form
Authorization for a minor to travel without an attendant
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Medical Necessity Form
To determine that the requested service meets program coverage guidelines, that the client is utilizing the closest approved medical provider and most appropriate type of service
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HIPAA Letter to Facilities in Regions 7 and 11 MTO
Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation in regions 7 and 11 MTO
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HIPAA Letter to Facilities in Region 8 MTO
Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation in Region 8 MTO
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Facility Services Web Portal Admin User Form
Request Form to Setup an Administrator Account for Requesting Transportation Online
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Covered and Non-Covered Services
Texas HHSC Medicaid Covered & Non-Covered Services
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