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MEDICAL TRANSPORTATION STATEMENT Case Name:Michigan Department of Health and Human Services Case Number: Date: MD HHS Office:If you do not understand this, call an MD HHS office in your area. MD HHS

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How to fill out msa-4674 medical transport statement

01

To fill out the MSA-4674 Medical Transport Statement, follow these steps:

02

Begin by entering the patient's personal information, including their name, address, date of birth, and contact details.

03

Next, provide details about the medical transport being requested, such as the type of transportation needed (e.g., ambulance, medical van), the purpose of the transport, and the date and time of the requested transport.

04

Fill in information about the patient's medical condition, including the diagnosis, any specific medical needs during transport, and whether the patient requires any medical equipment or medication during the transport.

05

If applicable, provide information about the healthcare provider or facility responsible for the patient's care, including their name, address, and contact details.

06

Finally, review the form to ensure all the necessary information has been provided and sign and date the document to certify its accuracy.

07

Please note that these are general steps, and additional sections or instructions may be included in the specific MSA-4674 form you are using. It is important to carefully read and follow the instructions provided with the form.

Who needs msa-4674 medical transport statement?

01

The MSA-4674 Medical Transport Statement is typically needed by individuals who require non-emergency medical transportation. This includes patients who are unable to transport themselves to medical appointments, treatments, or other healthcare-related services.

02

Common examples of individuals who may need to fill out this statement include elderly or disabled individuals, patients with mobility limitations, individuals undergoing ongoing medical treatments, and those who require specialized medical transportation services.

03

In some cases, healthcare providers or facilities may also need to complete this statement on behalf of their patients to request medical transportation services.

04

It is important to consult with the relevant healthcare providers or authorities to determine if the MSA-4674 Medical Transport Statement is required in your specific situation.

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