Intelliride Colorado Forms. for transportation for one of your patients. for transportation fo

for transportation for one of your patients. for transportation for one of your patients. • For mileage reimbursement, clients can submit the following form within 10 business days after their appointment. If you need a ride and live in any other Colorado county: Contact a local ride provider. gov/nemtlist. Please complete this form and return it to IntelliRide for reimbursement of your mileage within 10 business days of your medical appointment. Call Transdev/IntelliRide at 855-489-4999 (toll free) (State Relay 711). Please note that all out-of-state requests must be submitted directly to Health First Colorado (not to Transdev) for approval. You can find local ride providers at hcpf. You must work with your doctor to complete and submit an NEMT Air, Train, and Out-of-State Request form. o Clients must submit verification of attendance from the treatment provider along with the reimbursement request. Transdev manages non-emergency medical and non-medical transportation for Health First Colorado members in the state of Colorado. o Client must schedule trip with Transdev prior to the appointment. Please fill out this Level of Service Medical Recommendation Form completely and . com/colorado/. . Or go to transdevhealthsolutions. colorado. Member’s medical provider must complete the Verification Form for Transportation Services More Than 25 Miles to verify the medical necessity of trip requests that exceed 25 miles, one way. All NEMT forms and instructions can be found on the Provider Forms page under Claim Forms and Attachments. rovide any supporting information as needed. This form will be used to determine the patient’s most appropriate mode of transportation based on his. Address: City State: Zip: Medical Info Diagnosis that suppor.

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