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IEHP Member ID: Member Name:TRANSPORTATION REQUEST FORM (SNF & LTC) DC Date and Time: *Height:*Weight:Trach to Ventilator: Yes No Suctioning: Deep Mild Trach to Oxygen: Yes No Liter Flow: FIO2: Trach
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How to fill out iehp transportation form transportation

01
Obtain a copy of the iehp transportation form transportation.
02
Fill out all required personal information such as name, address, and contact details.
03
Provide information about the appointment or need for transportation services.
04
Specify the type of transportation needed (e.g. ambulance, wheelchair van).
05
Sign and date the form before submitting it to the appropriate contact or agency.

Who needs iehp transportation form transportation?

01
Individuals who are iehp members and require transportation assistance to get to medical appointments or services.
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The IEHP transportation form is used to request non-emergency medical transportation services provided by Inland Empire Health Plan (IEHP) for eligible members to access healthcare services.
Eligible IEHP members who need non-emergency medical transportation to attend medical appointments are required to file the IEHP transportation form.
To fill out the IEHP transportation form, you need to provide your personal information, details of the medical appointment, type of transportation needed, and any special accommodations required.
The purpose of the IEHP transportation form is to ensure that eligible members can access medical services by requesting appropriate transportation assistance.
The form requires reporting personal details such as name, address, contact information, appointment details, and specific transportation needs.
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iehp trach covid bariatric ctt ltc snf cucamonga fio2 bls suctioning ambulatory applicable caregiver als availability rancho org chemotherapy revised approximate ventilator vendor administered dialysis entity liter

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