Physician Referral Form - Vermont

Physician Referral Form
The Department of Vermont Health Access (DVHA) helps people on Medicaid or Dr. Dynasaur with
transportation to get to their medical appointments or pick up prescriptions. Please complete and sign
this form in order for us to determine if this trip should be covered by Medicaid. Please mail or fax the
form to:
Medicaid Transportation
DVHA
312 Hurricane Lane, Suite 201
Williston, VT 05495
Fax: (802) 879-5919
Client Name: ________________________________________________________________
Unique ID: _______________________ DOB: _____________
Appointment Date and Time: ____________________________________________________
Name of Primary Physician: ____________________________________________________
Name of Physician to whom
Client is Being Referred: ____________________________________________________
Address: ____________________________________________________
____________________________________________________
Phone: _________________________
Is overnight lodging necessary? Yes No
Medically, how many people should accompany the patient (other than the driver)? __________ Please
explain on next page.
Transportation Broker:
Address:
Phone:
DVHA Decision: Approved Denied
Authorized by: _____________________________________________________ Date: ___________
rev 7/14
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Physician Referral Form - Vermont PDF

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