Healthcare Providers DownloadsRegion SDA 1


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Standing Order Request Form

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

Parent Authorization Form - Spanish

Authorization for a minor to travel with a different adult than parent/guardian (Español)

Parent Authorization Form

Authorization for a minor to travel with a different adult than 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

Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation

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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