TX HHS Form 4214. Request for Non-Emergency Medical Transportation (NEMT) Services

The TX HHS Form 4214, Request for Non-Emergency Medical Transportation (NEMT) Services, is a crucial document that helps individuals request transportation to medical appointments. This form should be used when an individual requires non-emergency medical care and needs assistance with transportation.

This comprehensive form is divided into four sections: Managed Care Organization (MCO) Information, Member Information, Medical or Dental Appointment Information, and Special Instructions or Notes. The required information includes the appointment date, hospital stay details, and hospital discharge date. Common scenarios of use include requesting transportation for regular medical appointments or after a hospital stay.

The form's key features include the provision of special instructions or notes to provide additional context for the requested NEMT services. The TX HHS Form 4214 is an essential tool for individuals seeking non-emergency medical care and requires careful completion to ensure timely and effective transportation arrangements.