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1 H3018 Usage/Verification of Travel by Mass Transit to Healthcare Services To or to the Parents or Guardian of: ADDRESS Return the Enclosed Form to: Texas Medicaid Healthcare Partnership PO Box Austin, TX Client: Client Type: DOB: Eligibility ID: Number of Attendants: Medicaid xxxxxxxxx 3 Enclosed are your bus tickets for medical transportation. These may only be used for trips to healthcare services. Only you (and your attendant if one has been approved to accompany you) can use the tickets. Before more tickets will be sent to you, the enclosed form must be filled in by the healthcare provider and mailed to the address shown above. After you use all of the bus tickets (see tickets listed below), with signature verification from your healthcare provider, send the enclosed form to TMHP by mail. (When indicating use, appointment dates can be the same or different dates.) You must call the Medical Transportation Program office at five workdays (not counting weekends or holidays) before your next healthcare appointment to ask for more tickets. If you are eligible for tickets, we will send them to you. Please call us if we can help answer any questions. Sincerely, Medical Transportation Manager or Designee Enclosures: Authorization #: Ticket Type Total of Type Total Individual Tickets xxxxxxxxxxx Child Fixed Route Ticket 4 4 xxxxxxxxxxx Transfer Ticket 4 4 xxxxxxxxxxx Fixed Route Ticket 4 4
2 H3018-S Uso/Verificación de viaje por transporte público a servicios de atención médica Para los padres o el tutor de: ADDRESS Devuelva la forma adjunta a: Texas Medicaid Healthcare Partnership PO Box Austin, TX Cliente: Clase de cliente: FDN: Identificación de elegibilidad: Número de ayudantes: Medicaid xxxxxxxxx 3 Adjuntamos los boletos de autobús para su transporte médico. Solo se pueden usar para viajar a los servicios de atención médica. Solo usted (y su ayudante si se le ha aprobado uno para que lo acompañe) puede usar los boletos. Antes de que se le envíen más boletos, el proveedor de atención médica tiene que llenar la forma adjunta y esta se tiene que enviar a la dirección que aparece antes. Después de usar todos los boletos de autobús (vea los boletos que se muestran a continuación), con verificación de firma de su proveedor de atención médica, envíe a TMHP la forma adjunta por correo. (Cuando indique el uso, las fechas de las citas pueden ser las mismas o diferentes.) Usted tiene que llamar al Programa de Transportación Médica lo menos 5 días hábiles (sin contar los fines de semana o días festivos) antes de su próxima cita de atención médica para pedir más boletos. Si usted llena los requisitos para recibir los boletos, se los enviaremos. Por favor, llámenos si tiene preguntas. Atentamente Medical Transportation Manager or Designee Anexos: Núm. de autorización: Clase de boleto Total de la clase Total de boletos individuales xxxxxxxxxxx Child Fixed Route Ticket 4 4 xxxxxxxxxxx Transfer Ticket 4 4 xxxxxxxxxxx Fixed Route Ticket 4 4
3 H3018 Verification of Travel by Mass Transit to Healthcare Services Client Name: DOB: PCN: xxxxxxxxx MPCN: xxxxxxxxx Attendant Name: Provider Name: API#: xxxxxxxxxxx Total # Issued: 12 Date Issued: 04/03/2012 # Individual Tickets Issued: 4 Ticket Type: Child Fixed Route Format: Child Fixed Route Ticket Authorization # xxxxxxxxxx # Individual Tickets Issued: 4 Ticket Type: Transfer Ticket Format: Transfer Ticket Authorization # xxxxxxxxxx # Individual Tickets Issued: 4 Ticket Type: Fixed Route Ticket Format: Fixed Route Ticket Authorization # xxxxxxxxxx Eligible Client: As you use bus tickets, fill out each box (1 box for each appointment date). After you use all of the bus tickets (see tickets listed above) and get healthcare provider to sign form, send form to TMHP by mail. The date you use the ticket and the appointment date can be different. Ticket is any form of paper/token/punch card used by your bus company. If it takes 2 tickets, punches, or tokens for a oneway trip to your healthcare provider, the roundtrip for that appointment is 4 tickets. Enter 4 for the type ticket used on that date of service. Ticket use by date of service can change; the form must always have the actual number by ticket type that you used on a date of service. If your bus company transports you free of cost, (for example, free trip for clients under 5 years old), write that in the last line. If you do not use a ticket type for a trip, write 0 for that type of ticket. Important: Your doctor or healthcare provider must provide name, address, phone number, NPI number, and signature. Mail the form to TMHP, PO Box , Austin, TX Return unused tickets to Medical Transportation Program, Mail Code 083-2, P.O. Box 33440, San Antonio, TX # Child Fixed Route Ticket Single Tickets xxxxxxxxxxx Used: Must include NPI # Transfer Ticket Single Tickets xxxxxxxxxxx Used: # Fixed Route Ticket Single Tickets xxxxxxxxxxx Used: Must include signature # Child Fixed Route Ticket Single Tickets xxxxxxxxxxx Used: # Transfer Ticket Single Tickets xxxxxxxxxxx Used: # Fixed Route Ticket Single Tickets xxxxxxxxxxx Used:
4 H3018 Verificación de viaje por transporte público a servicios de atención médica Nombre del cliente: MPCN: xxxxxxxxxx FDN: Núm. de control del paciente: XXXXXXXX Nombre del ayudante: Nombre del Núm. de API: xxxxxxxx Núm. total emitidos: 12 Fecha de emisión: 04/03/2012 Núm. de boletos individuales 4 Clase de boleto: Child Fixed Formato: Child Fixed Route Ticket Núm. de autorización xxxxxxxxxx Núm. de boletos individuales 4 Clase de boleto: Transfer Ticket Formato: Transfer Ticket Núm. de autorización xxxxxxxxxx Núm. de boletos individuales 4 Clase de boleto: Fixed Route Formato: Fixed Route Ticket Núm. de autorización xxxxxxxxxx Cliente que llena los requisitos: Cuando use el boleto de autobús, llene cada casilla (una casilla por cada fecha en que tuvo cita). Una vez que haya usado todos los boletos de autobús (vea los boletos que aparecen antes) y haya obtenido la firma del proveedor de atención médica, envíe la forma por correo a TMHP. La fecha en que usó el boleto y la fecha de la cita pueden ser diferentes. Un "boleto" es cualquier tipo de papel, ficha o tarjeta perforada que usa la compañía de autobuses. Si se usan 2 boletos, perforaciones o fichas para un viaje de ida a la cita de su proveedor de atención médica, para el recorrido de ida y vuelta son 4 boletos. Escriba 4 para la clase de boleto usado en la fecha de ese servicio. El boleto usado por fecha de servicio puede cambiar; la forma tiene que tener el número por clase de boleto que usted usó en la fecha del servicio. Si la compañía de autobuses lo lleva gratis (por ejemplo, si el viaje es gratis para los clientes menores de 5 años), escriba eso en la última línea. Si usted no usa una clase de boleto para un viaje, escriba 0 para esa clase de boleto. Importante: Su doctor o proveedor de atención médica tiene que dar el nombre, dirección, teléfono, número de identificación nacional del proveedor y firma. Envíe esta forma por correo a: TMHP, PO Box , Austin, TX Devuelva los boletos no usados a: Medical Transportation Program, Mail Code 083-2, P.O. Box 33440, San Antonio, TX Debe incluir su número de NPI
5 H3018 Verification of Travel by Mass Transit to Healthcare Services Provider Name: API#: xxxxxxxxx Total # Issued: 12 Date Issued: 04/03/2012 # Individual Tickets Issued: 4 Ticket Type: Child Fixed Route Format: Child Fixed Route Ticket Authorization # xxxxxxxxxx # Individual Tickets Issued: 4 Ticket Type: Transfer Ticket Format: Transfer Ticket Authorization # xxxxxxxxxx # Individual Tickets Issued: 4 Ticket Type: Fixed Route Ticket Format: Fixed Route Ticket Authorization # xxxxxxxxxx # Fixed Route Ticket Single Tickets xxxxxxxxxx Used: # Fixed Route Ticket Single Tickets xxxxxxxxxxx Used: # Fixed Route Ticket Single Tickets xxxxxxxxxx Used: # Fixed Route Ticket Single Tickets xxxxxxxxxx Used:
6 H3018 Verificación de viaje por transporte público a servicios de atención médica Nombre del Núm. de API: xxxxxxxxx Núm. total emitidos: 12 Fecha de emisión: 04/03/2012 Núm. de boletos individuales 4 Clase de boleto: Child Fixed Formato: Child Fixed Route Ticket Núm. de autorización xxxxxxxxxx Núm. de boletos individuales 4 Clase de boleto: Transfer Ticket Formato: Transfer Ticket Núm. de autorización xxxxxxxxxx Núm. de boletos individuales 4 Clase de boleto: Fixed Route Formato: Fixed Route Ticket Núm. de autorización xxxxxxxxxx
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