Downloads

Please click on the Download link that corresponds to the document you would like to view, and then click on Open or Save when prompted.

 TitleDescription 
Closest Provider CertificationCPC Form for MileageDownload
CT DSS Facility NEMT BrochureHow to Access Non-Emergency Medical TransportationDownload
CT DSS NEMT Brochure [Spanish]Como acceso No son de emergencia Transporte medico Download
State MapA Map which shows the CT DSS Husky A, C and D Medicaid members service areaDownload
Companion Referral FormForm that is used to approve medical necessity for companions and aidesDownload
Covered/Non-Covered Service ListList of most common covered/non-covered services for Non Emergent TransportationDownload
CT DSS Hospital NEMT BrochureHow to Access Non-Emergency Medical TransportationDownload
Child Consent FormChild Consent FormDownload
CT Physician Transportation Restriction FormCT Physician Transportation Restriction FormDownload
CT Single Trip RequestCT Single Trip RequestDownload
CT Standing OrderCT Standing OrderDownload
Facilities Gas Reimbursement clarification letterFacilities Gas Reimbursement clarification letterDownload
Child Consent Form - SpanishChild Consent Form - SpanishDownload
Gas Reimbursement GuidelinesGas Reimbursement GuidelinesDownload
Gas Reimbursement Invoice FormGas Reimbursement Invoice FormDownload
How to submit a complaintHow to submit a complaintDownload
 

Any facilities having specific questions or concerns, please contact LogistiCare's Facility Outreach Coordinator, Jennifer Matos at Jenniferm@logisticare.com

 

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