Healthcare Providers DownloadsMTO Regions


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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

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

Parental Authorization Form - Spanish

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

Parental Authorization Form

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

Minor Consent Form

Authorization for a minor to travel without an attendant

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

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

HIPAA Letter to Facilities in Region 8 MTO

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

Facility Services Web Portal Admin User Form

Request Form to Setup an Administrator Account for Requesting Transportation Online

Covered and Non-Covered Services

Texas HHSC Medicaid Covered & Non-Covered Services
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