Georgia Facility Network

GeorgiaFacility Network

Downloads

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 TitleDescription
Central Single Trip RequestCentral Single Trip Request
Complaint FormUsed by facilities to file a complaint
East Single TripEast Single Trip
Facility Information BrochureHow to Access Non-Emergency Medical Transportation (NET) for Georgia Medicaid Members
GA Standing Order CentralGA Standing Order Central
GA Standing Order EastGA Standing Order East
GA Standing Order SouthwestGA Standing Order Southwest
Level of Service FormLevel of Service Form
Medical Provider EDI FormForm is to request access to enter standing orders on-line
Mileage Reimbursement Form 2016Blank Mileage Reimbursement Forms for download or printing
Mileage Reimbursement Information 2016Mileage Reimbursement Program information, payment schedule and instructions
NET Medical Necessity FormNET Medical Necessity Form
Service Area MapIndicates Counties LogistiCare Serves in Georgia
Southwest Single Trip RequestSouthwest Single Trip Request
UHC CIP Mileage Reimbursement FormA form required for a rider who has someone to provide transportation to the appointment. The form is completed by the rider, signed by the physician and submitted to LogistiCare for mileage/gas reimbursement.
UHC CIP Mileage Reimbursement LetterA letter that describes the required process for members participating in the mileage reimbursement program.

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