Virginia Facility Network

Virginia Facility Network

Downloads

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 TitleDescription
Attendant Care Eligibility Assessment FormAn eleven question assessment that provides descriptive information regarding a member’s behavior during transport. This assessment is used in the attendant approval/denial process.
Attendant Pre Assessment ChecklistTool used to assist the preparer in determining if a member qualifies for an attendant prior to completing the Attendant Care Eligibility Assessment form.
Chartered Health Members Access to NETInforms members how to access non-emergency medical transportation
Chartered Health Plan FlyerInforms members what to do to utilize non-emergency transportation.
Child Consent Form - EnglishChild Consent Form - English
Child Consent Form - SpanishChild Consent Form - Spanish
Mileage Reimbursement InstructionsExplains the criteria and how the members are reimbursed.
Mileage Reimbursement Trip LogA form, which must be completed by a medical professional, when requesting transportation for a member that has access to a vehicle or can be transported by a friend or relative.
LogistiCare 5 Day Notice Requirement FlyerInforms members a 5 day notice is required to schedule non-emergency transportation
Single Trip Request FormSingle Trip Request Form
Standing Order FormStanding Order Form
Tips for Arranging Medicaid Non-Emergency TransportationProvides Tips for members on how to arrange Medicaid Non-Emergency Transportation.
Unison Health Plan Facility FlyerInforms members how to access non-emergency medical transportation
Unison Health Plan FlyerInforms members what to do to utilize non-emergency transport
VA Level of Service FormVA Level of Service Form
VA Operations Contact ListPhone numbers for the Virginia Management Team.
Volunteer Driver FlyerInforms who volunteer drivers are and lists the requirements of becoming a volunteer driver

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