Iowa Facility Network

IowaFacility Network

Downloads

Please click on the title that corresponds to the document you would like to view, and then click on print or download as necessary.

 TitleDescription
Ancillary FormUsed for requesting long-distance trips, meals and/or lodging
Discharge ManualGuide for requesting discharges for members in need of transportation
Iowa Facility Registration FormRequired for facilities requesting trips/standing orders
Iowa Medical Facility EDI FormRequired for scheduling transportation online (facility.logisticare.com)
Iowa Mileage Reimbursement FormForm used for Mileage Reimbursement
Iowa Mileage Reimbursement InstructionsInstructions on how to receive Mileage Reimbursement
Level of Service FormRequired for members needing Wheelchair or Stretcher levels of service
Minor Consent FormRequired for minors to be transported without an escort
Minor Consent Form - SpanishConsentimiento y liberacion de responsabilidad para los menores
Physician Transportation Restriction FormRequired for members unable to use certain types of transportation
Single Trip RequestUsed for requesting a single trip
Standing Order FormUsed for requesting recurring appointments (e.g. dialysis, physical therapy, etc.)

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