NY Manual
SHP Manual

New York Provider Manual
VIII Description of Skilled Nursing Service | IX-B Member Transportation Reimbursement Form

Appendix IX — Healthfirst Transportation

Appendix IX-A — Provider Approval Form

Instruction: This form should be completed and signed by the provider responsible for the physical or behavioral health of the Healthfirst member indicated below. If the member requires medically necessary, non-emergency taxi, ambulette, or ambulance transportation to and from medical services, please fax a completed form to Member Services at 1-212-801-3250.

Member Name:                                                                                   CIN Number                                         
Required Mode of Transportation:  Taxi/Liveryc   Ambulettec   Ambulancec    Other:______________________
Extent for Requirement: No. Trips:                          -and- From:                                   Thru:                             
                                                                                             MM/DD/YY                        MM/DD/YY
Medical Justification (please indicate diagnosis and why it prevents member from using public transportation):  
Other Assistance Required:  c Wheelchair   c Stretcher   c Other     _______________________
Provider Signature                                              Phone Number                     Date
Provider Name (please print)                               Healthfirst ID #                     Hospital Affiliation
COMPLETED FORMS:  Healthfirst Member Services Transportation
P.O. Box 5165
New York, NY 10274
Fax: 1-212-801-3250
Phone: 1-866-463-6743