Maryland Statewide Medical Assistance Transportation Transfer and

Maryland Department of Health - Cecil County Health Department

Medical Assistance Transportation Program Phone: (410) 996-5171

401 Bow Street, Elkton, Maryland 21921 FAX: (410) 996-1020

After hours: (410)920-4167

MARYLAND STATEWIDE MEDICAL ASSISTANCE TRANSPORTATION TRANSFER/DISCHARGE FORM

SECTION 1 - PATIENT PERSONAL INFORMATION:

Last Name:

First Name:

Height:

Weight:

DOB:

Address:

City/State/Zip:

Bldg or Facility

Name:

Room/Bed #

Patient Contact/Phone:

Medical Assistance #:

Social Security # (Optional):

Medicare #:

Other Insurance:

Is this recipient staying in a Skilled Nursing Facility under a Medicare Part A admission? Yes No

(If Yes, Limited Transportation Benefits May Be Available To These Recipients. Please Contact Your Local Health Department MA Transportation Unit)

SECTION 2 –FACILITY DISCHARGES and TRANSFERS INFORMATION:

Pick-Up Information

Destination Information

Facility

Address

Zip Code

Address

Zip Code

Room/Suite/Floor

Sending Facility

Contact Person

Name: Phone: Fax:

Date: Time:

Authorization #:

SECTION 3 - MEDICAL DIAGNOSIS and CONDITION List the UNDERLYING MEDICAL DIAGNOSIS and describe the MEDICAL CONDITION (physical and/or mental) of this participant that requires

the recipient to be transported in ambulance, wheelchair or Metro rail/bus/sedan and why transport by other means is contraindicated by the participant’s condition:

Underlying Medical Diagnosis (DO NOT Enter ICD or DSM Codes)

Medical Condition (Symptoms)

SECTION 4 – CHOOSE ONLY ONE CLINICALLY APPROPRIATE MODE OF TRANSPORTATION

a) AMBULATORY/ABLE TO WALK (with mobility aides): Enter distance of ambulation in feet:______________________

Client may be transported by: Paratransit vehicle Public transit system Cab/Sedan

b) WHEELCHAIR Check Type: REGULAR W/C ELEC. W/C ELECTRIC SCOOTER X-WIDE W/C SPECIALTY W/C

Please check environmental conditions that are applicable: _______ RAMP, _______ STEPS If steps, give # ________ OTHER _________________________________

c) AMBULANCE - Check Appropriate Level ( justify below if other than BLS) BLS ALS SCT/P SCT/N NEO-NATAL

Clinical Interventions Necessitating Ambulance:_________________________________________________________________________________________________

Please check building access that is applicable: _______ RAMP, _______ STEPS If steps, give # ________ OTHER

___________________________________________water mark

All of the following questions must be answered for this form to be valid:

1) Can this patient safely be transported by sedan or wheelchair van (that is, seated and secured during transport)? Yes No

2) Is this patient “bed confined” as defined below? Yes No

To be “bed confined” all three of the following conditions MUST be met: (A) The recipient is unable to get up from bed without assistance; AND ( B) The recipient is unable to

ambulate; AND (C) The recipient is unable to sit in a chair or wheelchair. Hospital discharge of wheelchair patient – w/c not sent with patient

3) If not bed confined, reason(s) ambulance service is needed (check all that apply):

Requires continuous O2 monitoring. (see instructions) Decubitus ulcers – Stage & Location:______________ Ventilator dependent

Orthopedic Device – Describe:__________________________ DVT requires elevation of lower extremities Requires airway monitoring/suctioning

IV Fluids/Meds Required-Med:__________________________ Restraints (physical/chemical) anticipated/used during transport Contractures

Cardiac/hemodynamic monitoring required during transport Bariatric Stretcher Please Explain:__________________ Other -Describe:______________

PSYCH TRANSFERS ( if applicable): Circle one →(Voluntary) or (Involuntary): Sedated; [Y] [N] Restrained; [Y] [N] Combative; [Y] [N] Other______

SECTION 5 - PROVIDER CERTIFICATION: To be FULLY completed by the classifications listed below.

By signing this form, you are certifying:

1. The services described are medically necessary AND

2. You understand that information provided is subject to investigation and verification. Misrepresentation or falsification of essential information which leads to inappropriate payment may

lead to sanctions and/or penalties under applicable Federal and/or State law.

Check Signee Type: PHYSICIAN PA CRNP DISCHARGE NURSE SOCIAL WORKER

Signature of Signee:

Date Signed:

Treating Provider/Facility Medical Assistance or NPI Number:

Printed Name of Signee:

Telephone #:

Printed Full Address of Signee:

Revised 7/2018

Instructions to Complete the Maryland Statewide Transfer / Discharge Form

PLEASE PRINT CLEARLY & COMPLETELY – FAILURE TO DO SO WILL RESULT IN DELAYS AS INCOMPLETE AND ILLEGIBLE FORMS MUST BE RETURNED

Section 1 – PATIENT INFORMATION – must be completed by facility

Patient’s Name and Address

Enter the patient’s Last Name, First Name. A complete and correctly spelled name is crucial for proper

patient identification. Enter the patient’s home address. If the patient is a resident of an inpatient facility,

enter the name and address of the facility along with room and bed number.

Telephone Number

Enter the contact number for the patient (i.e. home telephone or cell number). If patient is a resident of an

inpatient facility, enter the inpatient facility telephone number.

Date of Birth, Weight & Height

Enter the patient’s date of birth as mm/dd/yyyy. Enter weight & height

Patient’s Social Security #

The patient’s social security number is optional.

Patient’s 11-digit MA #

Enter the patient’s 11-digit Medical Assistance number. Do not enter the MCO identification number.

Patient’s Medicare #

If applicable, enter the patient’s 9-digit Medicare number along with the applicable “letters”

Other Insurance

If applicable, enter other insurance information – ID number and name of other insurance

Part A Participant

Subsequent to regular screening, verify if requested transport does not qualify for Medicare Part A

coverage. If not covered by Medicare and the participant is eligible through screening, schedule the trip.

Section 2 – FACILITY DISCHARGES and TRANSFER INFORMATION

Name of Facility

Enter name and address of facilities, sending and receiving, including floor and room number

Facility Full Address

Enter Facilities full address. We will utilize this to transport the patient for the appointment

Floor / Room Information

Enter floor and room for sending and receiving facility if applicable

Contact Person

Enter name and phone, fax of person program should contact if additional information is required.

Date & Time of Transport

Enter date and time of transport

Authorization

Enter a behavioral health or LHD Authorization number if applicable

Section 3 – MEDICAL DIAGNOSIS and CONDITION

Medical Diagnosis

DO NOT ENTER ICD OR DSM code. Spell out primary and secondary diagnosis for

which you are providing treatment. Be as comprehensive as possible.

Medical Condition

Spell out symptoms of the medical condition. Providing this information may support the

diagnosis, however, will not provide medical justification for transportation. i.e. “Knee

pain” does not medically justify the need for transportation as it is a symptom.

Section 4 – CHOOSE ONLY ONE MODE OF TRANSPORTATION

Indicate type of transportation

needed

* Ambulatory/Able to Walk

* Wheelchair Type

* Ambulance

Choose only one (1) certified mode of transportation. Check appropriate box.

If wheelchair, check type of wheelchair and indicate applicable condition(s) – ramp, steps w/ #, other.

If ambulatory/able to walk, enter distance.

If ambulance, check appropriate level. If other than BLS, Indicate applicable condition(s) – ramp, steps

with number of steps, other.

If the ambulance is needed only due to wheelchair dependency without wheelchair at the hospital, that

must be indicated by selecting: Hospital discharge of wheelchair patient – w/c not sent with patient

If ambulance transport is necessary, questions 1, 2, and 3 MUST be answered, no exceptions.

Psych Transfers

If applicable circle one

Section 5 – PROVIDER CERTIFICATION: To be FULLY completed by the classifications listed below

Signee Type

The Signee should check the appropriate box attesting to the information on this form.

Signature

Signature of signee is mandatory or will be returned which will delay transportation services.

Date Signed

Enter date signed. This form is valid for a period of one year from the date of signing unless the patient’s

condition warrants recertification or as may be required by the local health department.

Facility’s NPI #

Enter Treating Provider or Facility’s NPI #. This number is needed to verify participation in the Medicaid

program.

Provider’s Telephone #

Enter Signee’s telephone number. We may need to contact you.

Provider’s Full Address

Enter Signee’s full address. We will utilize this to transport the patient for the appointment.

Incomplete forms will be returned to the Facility and may delay transportation services