Physician Certification Statement of Medical Necessity for NEMT
Providers are required to complete this form for each member requiring non-emergency medical transportation (NEMT) before transportation can be approved.
In order to appropriately evaluate your request, complete all form fields below, including provider signature and date of signature. If any field is incomplete, further documentation may be requested. This form constitutes a prescription.
(References: California Code of Regulations (CCR), Title 22, Section 51003, 51303, 51303, 51323 and Medi-Cal Provider Manual).
Contact Provider Services
General | 831-430-5504 |
Claims Billing questions, claims status, general claims information |
831-430-5503 |
Authorizations General authorization information or questions |
831-430-5506 |
Authorization Status Checking the status of submitted authorizations |
831-430-5511 |
Pharmacy Authorizations, general pharmacy information or questions |
831-430-5507 |