Form Mt-3 Verification Of Medical Transportation
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1
2Form MT-3 (Revised 01/14)
VERIFICATION OF MEDICAL TRANSPORTATION
Single Appointment:
Weekly Appointments:
Date of Appointment: ______/______/_________
Week of Appointments: _____/_____/______ - _____/_____/_____
Time of Appointment: _______________AM / PM
Days Transported: Sun
Mon
Tue
Wed
Thu
Fri
Sat
RECIPIENT VERIFICATION OF MEDICAL TRANSPORTATION
I.
Transportation Provider Name _________________________________________________________________________
Recipient’s Name_____________________________________________ Medicaid I.D.___________________________
Recipient’s Address _________________________________________________________________________________
Street
City
State
ZIP Code
Appointment Address________________________________________________________________________________
Street
City
State
ZIP Code
Having no other form of transportation to receive medical treatment under the Medicaid program, I have requested transportation
services from the Department of Health and Hospitals. My signature below acknowledges that I am using transportation to keep a
medical appointment. I understand that transportation services can only be used to receive medical services. I understand that if I do not
sign this request for medical transportation and return it to the transportation provider, the Department of Health and Hospitals or a duly
appointed representative may choose to contact me or the medical provider I am being transported to for the verification that I have
kept my medical appointment.
___________________________________________
________________________
Recipient’s Signature
Date
II.
DRIVER VERIFICATION
Check appropriate block(s)
I certify that I was the driver who provided the above named recipient with transportation to the medical facility.
_______________________________________
_____________________
Driver’s Signature
Date
I certify that I was the driver who provided transportation for the above recipient from the medical facility to the
recipient’s home.
_______________________________________
_____________________
Driver’s Signature
Date
III. MEDICAL SERVICE PROVIDER VERIFICATION
This section must be completed by the medical service provider or his/her representative and returned to the transportation provider by
the recipient when the recipient is picked up after the medical appointment. Completion of this section by the signature of anyone other
than the medical provider or his/her representative who rendered the services is prohibited and may result in prosecution.
I certify that the above named recipient had an appointment(s) on __________________________________________________
at ________________ AM / PM and received medical services.
(specify date/dates)
I certify that the above named recipient was in the office on _______/_______/_______ at ___________ AM /PM but did not
receive medical services because____________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________
____________________
Office Stamp (Optional)
Signature and Title
Date
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