Non-Emergency Ambulance Transportation Prior Authorization Form

Enter Member ID and Date of Birth to validate Member Details.

Please refer to Neighborhood’s Clinical Medical Policy which is available on our Neighborhood web site, www.nhpri.org for more detailed information about this benefit, authorization requirements, and coverage criteria.

- Member Name*
  First Last
- Member's ID #*
- Member's DOB*
- Ambulance Company Name*
- Ambulance Company NPI*
- Phone # (Ex: 401-111-1234)*
- Fax # (Ex: 401-111-1234)**
- Contact Name*
  First Last
- Email*
  
  Email address in order to receive confirmation of request receipt
- Date of Service
- Clinical Information
- How many HCPC codes do you want to enter?
- 1) HCPC Code
  *HCPC code and two-digit modifiers (*the first digit identifies the ambulance’s place of origin; the second digit identifies the destination.):*
- Unit*
- Primary Diagnosis*
- Primary Diagnosis ICD 10 code*
- Type of Ambulance Needed*
  - Stretcher Ambulance
  - Wheelchair Ambulance
- Who Requested Ambulance*
- Place of Origin (e.g. name of hospital, group home, etc)*
- Destination (e.g. name of nursing home, member’s home, etc)*
- Medical Necessity Information
  If available, please indicate treating clinician who provided the information and their location. If no information available, please leave blank and Neighborhood will obtain.
- Clinician name
- Clinician Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Medical Condition(s)*
  which prevents safe transportation by any other means
- Please indicate the purpose of transfer*
- Request Method*
  - Standard
  - Expedited
  By checking off Expedited you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
- Attachment*
  Accepted file types: pdf.
- Comment Box

Clinical Information

Medical Necessity Information