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WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES APPLICATION FOR EMERGENCY MEDICAL TRANSPORTATION PROGRAM (NEXT) Section I: TO BE COMPLETED BY APPLICANT. Note: This must be completed in ink
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How to fill out ofa nemt 1doc
How to fill out OFA NEMT 1doc:
01
Start by entering your personal information in the designated fields. This includes your full name, address, and contact details.
02
Next, provide your insurance information, including the name of your insurance provider and your policy number.
03
In the medical information section, list any existing medical conditions or allergies that may be relevant for transportation purposes.
04
Indicate the type of transportation needed by selecting the appropriate options, such as wheelchair-accessible vehicles or stretcher transportation.
05
Specify the dates and times of the requested transportation. Be as accurate as possible to ensure smooth coordination.
06
If you require any special medical equipment during transportation, make sure to mention it in the appropriate section.
07
Finally, sign and date the document to validate your request.
Who needs OFA NEMT 1doc:
01
Individuals who require non-emergency medical transportation services to travel to and from medical appointments or healthcare facilities.
02
Patients with physical disabilities or medical conditions that prevent them from using regular means of transportation.
03
Seniors or individuals who are unable to drive and need assistance commuting for medical purposes.
04
People in rural areas or areas with limited public transportation options who require specialized transportation services.
05
Individuals who have been advised by their healthcare provider to use non-emergency medical transportation due to their medical condition or treatment requirements.
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