Healthcare Providers DownloadsMTO Regions

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

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

Authorization for a minor to travel with a different adult then parent/guardian

Authorization for a minor to travel with a different adult then parent/guardian

Authorization for a minor to travel without an attendant

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

Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation in regions 7 and 11 MTO

Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation in Region 8 MTO

Request Form to Setup an Administrator Account for Requesting Transportation Online

Texas HHSC Medicaid Covered & Non-Covered Services