South Carolina Facility Network

South CarolinaFacility 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
Facility BrochureFacility Brochure
Complaint FormA form used to document a complaint.
Medical Necessity FormMedical necessity form.
Dialysis - Standing Order FormA form used to request a standing order for plan members requiring dialysis.
Adult Day Care Mental Health - Standing Order FormA form used to request a standing order for plan members to their adult day care or mental health appointments.
Mass Transit Rider FormForm to be completed by licensed medical professional when a member cannot use mass transit.
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.
Mileage Reimbursement LetterA letter that describes the required process for members participating in the mileage reimbursement program.
Compliment FormA form that may be mailed or faxed to say thank you for a job well done. This may include, but is not limited to, drivers, Customer Service Representatives in the call center, Facility Department specialists or other individuals who help make your patient
Mileage Reimbursement Letter in SpanishMileage Reimbursement Letter in Spanish
Mileage Reimbursement Form in SpanishMileage Reimbursement Form in Spanish
Rider HandbookRider rights and responsibilities while using transportation and how to contact LogistiCare.

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