Medical Certification of Transportation Services: Beyond 25 Miles

  • The patient's medical provider completes this form which will be used to verify that any trip requested over 25 miles has been confirmed as needed by the member's medical provider. An established relationship or there are no closer providers to this member that can provide needed service are the reasons for submittal. This information can be called in, faxed, emailed, completed online at medicaidco.com or mailed to Veyo.
  • Patient Information:

  • Medical Facility Information:

  • Agreement and signature:

    I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil, or both. I certify under penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the information provided is accurate to the best of my knowledge.
  • Type Full Name to Denote Signature
  • This form has changed and is no longer required to expire after 6 months.

    **Please call (855.264.6368) to verify the form was approved 2 business days after you submit the form.**


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