A resource for all of the provider related forms and documents that a doctor will need when working with bmc healthnet plan. Prescription orf transportation pt1 sections 1 through 8 of the pt1 form must be filled out completely by the provider, including critical data listed below. Your medical masshealth provider may also request this form. Members name, masshealth id, date of birth locality justification if applicable duration and frequency. Download printable form pt1 in pdf the latest version applicable for 2020. You must have an approved pt1 form from your provider. Pt 1 form fill out and sign printable pdf template signnow. The providers signature indicates that all information contained on the form is accurate to the best of hisher knowledge. Customer web portal is for the submission of provider requests for transportation pt1 and. Frta policy for ma health pt1 transportation frta franklin. Completion of the prescription for transportation pt1 form for transportation to day habilitation programs please indicate the type of request new form section 1 masshealth member information please complete the masshealth member information requested. Free printable 2019 massachusetts form 1 and 2019 massachusetts form 1 instructions booklet in pdf format to print, fill in, and mail your state income tax return due april 15, 2020.
Transportation massachusetts health care training forum. Home association of developmental disabilities providers. For more detailed information about the masshealth transportation benefit, consult the masshealth. To complete the provider request for transportation form pt1, you. Video instructions and help with filling out and completing pt1 form. Masshealth customer web portal and forms and publications. Provider requests for transportation pt 1 nonemergency medical transportation nemt is a limited transportation benefit that is provided to eligible masshealth members who have no other way of getting to their medical, behavioral health, or dental appointments. Form pt1 download printable pdf or fill online prescription for. To complete the provider request for transportation form pt1, you will also need.
Bmc healthnet plan is a nonprofit managed care organization that has provided health insurance coverage to massachusetts residents for more than 20 years. Call masshealth customer service center for providers, tty. Please contact the disability accommodation ombudsman for assistance at 617 8473468 tty. What you need for request transportation for a member to request transportation for a member, you will need a customer service web portal account. Any notification that you may receive from our office is a courtesy on our part. If there is a known respite address, please enter as the alternate pick up address. Please click the forgot or dont have a password link below. Instructions for completing and submitting or viewing the pt1 form online open mondayfriday 8 a. Note that you have to complete part 1 as well as part 2, section 1, and. Fill out the prescription for transportation form massachusetts online and.
Instructions for completing and submitting or viewing the pt1 form online. Committed to enhancing political, financial, and educational health of member organizations that serve people with disabilities, including intellectual and developmental disabilities and acquired brain injuries. Pt1 form fill online, printable, fillable, blank pdffiller. How to complete and submit or view the pt1 online mass. Masshealth prescription for transportation form pt1 pdf masshealth. It is your responsibility to know the expiration dates of your pt1 forms. Masshealth provider forms masshealth will provide the publications in accessible formats upon request.