Fillable Printable Physician Referral Form - Vermont

Physician Referral Form - Vermont

Physician Referral Form

The Department of Vermont Health Access (DVHA) helps people on Medicaid or Dr. Dynasaur with

transportation to get to their medical appointments or pick up prescriptions. Please complete and sign

this form in order for us to determine if this trip should be covered by Medicaid. Please mail or fax the

form to:

Medicaid Transportation

DVHA

312 Hurricane Lane, Suite 201

Williston, VT 05495

Fax: (802) 879-5919

Client Name: ________________________________________________________________

Unique ID: _______________________ DOB: _____________

Appointment Date and Time: ____________________________________________________

Name of Primary Physician: ____________________________________________________

Name of Physician to whom

Client is Being Referred: ____________________________________________________

Address: ____________________________________________________

____________________________________________________

Phone: _________________________

Is overnight lodging necessary? Yes No

Medically, how many people should accompany the patient (other than the driver)? __________ Please

explain on next page.

Transportation Broker:

Address:

Phone:

DVHA Decision: Approved Denied

Authorized by: _____________________________________________________ Date: ___________

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Please check “yes” or “no” to all of the following questions:

Yes No

Is this service obtainable in Vermont?

Have efforts been made to find a closer provider?

Does the requested physician possess special expertise?

Is it medically necessary for this physician to treat this patient?

Does the patient have a history with this specific provider?

Can another physician take over this case if a history does exist?

If this is an out-of-state/out-of-network request, is a Clinical prior

authorization in place?

Please describe the specific service or medical care that this member needs a ride to:

__________________________________________________________________________________

Is there a medical reason for someone to accompany the member on this trip?____________________

__________________________________________________________________________________

If necessary, please add any further information: ___________________________________________

__________________________________________________________________________________

_____________________________________________________ ________________

Print name of Doctor or Doctor’s Staff providing information Phone

_____________________________________________________ _______________

Signature of Doctor or Doctor’s Staff providing information Date