List any additional stops, return trips, or special routing(e.g., pharmacy, return to facility, etc.)

Select the type of transport needed

Required if payer type is MCO.

For Inclusa members: transportation is typically coordinated through MTM. However, if MTM is unable to secure transport and Inclusa authorizes service directly, please indicate Inclusa for direct billing.

Only complete this if payer type is MCO. For Inclusa memebers, transportation is typically routed through MTM, IF MTM is unable to secure transport and Inclusa authorizes service directly, select Direct.

Required when authorization has been provided by the MCO or broker (MTM, Inclusa, etc,)

Use only if an MCO has directed direct billing outside the normal broker route. Example: MTM unable to secure transport; Inclusa approved direct billing.

If you selected "Other"please describe your relationship to the patient

System will apply appropriate rates based on time of service