Healthcare Facility Downloads

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Attendant Care Eligibility Assessment FormAn eleven question assessment that provides descriptive information regarding a member’s behavior during transport. This assessment is used in the attendant approval/denial process.Download
Medicaid Expansion PosterMedicaid Expansion “New Health Care Coverage for Adults”Download
Single Trip Request FormForm used for one time trip requests such as doctor visit, follow up appointments, etc.Download
Attendant Pre-Assessment ChecklistTool used to assist the preparer in determining if a member qualifies for an attendant prior to completing the Attendant Care Eligibility Assessment form.Download
Consent and Release of Liability FormMust be completed by a parent or legal guardian when requesting transportation for minor children attending Medicaid paid programs. This form must be completed and returned to LogistiCare’s Utilization Review Department prior to the transport date.Download
FFS Mileage Reimbursement Trip Log and InstructionsA form, which must be completed by a medical professional, when requesting transportation for a member that has access to a vehicle or can be transported by a friend or relative.Download
LogistiCare 5 Day Notice Requirement Flyer for Routine AppointmentsInforms members a 5 day notice is required to schedule FFS non-emergency transportation routine appointments.Download
Medical Necessity FormMust be completed by a medical professional or qualified case manager. This form may be required if a level of service is questionable when requesting transportation for a member that is not able to walk.Download
Tips for Arranging Medicaid FFS Non-Emergency TransportationProvides Tips for members on how to arrange Medicaid FFS Non-Emergency Transportation.Download
Standing Order FormA form used to request recurring transportation for a member that goes to the same facility one or more times per week.Download
Volunteer Driver FlyerInforms who volunteer drivers are and lists the requirement of becoming a volunteer driver.Download
Complaint Form and InstructionsDocument used to submit a written complaint.Download

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