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Baltimore County Department of Health Medical Assistance Transportation Program 6401 York Road, Baltimore, Maryland 21212 PHONE: (410) 8872828 FAX: (410) 3778296 MARYLAND STATEWIDE MEDICAL ASSISTANCE
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How to fill out medical assistance transportation request
How to fill out medical assistance transportation request
01
Obtain a medical assistance transportation request form from the healthcare provider.
02
Fill out the patient's personal information including name, address, date of birth, and insurance information.
03
Provide details of the medical appointment or treatment that requires transportation assistance.
04
Specify the preferred mode of transportation such as ambulance, wheelchair van, or public transportation.
05
Sign and date the form, and make sure all information is accurate and complete.
Who needs medical assistance transportation request?
01
Individuals who are unable to drive or have mobility issues that prevent them from getting to medical appointments on their own.
02
Patients who require specialized medical transportation due to their medical condition or treatment needs.
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What is medical assistance transportation request?
Medical assistance transportation request is a form used to request transportation services for individuals who require medical attention or assistance.
Who is required to file medical assistance transportation request?
The individual or their caregiver who needs medical transportation assistance is required to file the request.
How to fill out medical assistance transportation request?
To fill out the medical assistance transportation request, the individual must provide their personal information, medical condition, preferred mode of transportation, and the date and time of the appointment.
What is the purpose of medical assistance transportation request?
The purpose of the medical assistance transportation request is to ensure that individuals with medical needs have access to transportation services to get to their medical appointments.
What information must be reported on medical assistance transportation request?
The information that must be reported on the medical assistance transportation request includes the individual's name, address, contact information, medical condition, and appointment details.
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