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, helps individuals who require medical or dental appointments to access transportation services. This form is typically used by patients with mobility issues or those living in remote areas where public transportation is limited.

This form requires the following information: managed care organization details, member information, and medical or dental appointment specifics, including date and type of appointment (hospital stay, regular appointment, or hospital discharge). The form also includes a section for special instructions or notes. By providing this essential data, individuals can ensure that their transportation needs are met in a timely and efficient manner.

Key features of the Form 4214 include:

• A comprehensive outline of required information to facilitate NEMT services
• A clear distinction between hospital stay, regular appointment, and hospital discharge dates
• A section for special instructions or notes to accommodate unique circumstances