​​Non-Emergent Medical Transportation Request Form

​Complete this form to request Non-Emergent Medical Transportation (NEMT) for Health First Colorado members who need in-state transportation or out-of-state transportation. Please note, the Department must be pre-approve all out-of-state requests prior to date of service and the Member must be eligible for NEMT services in order for authorization to be granted. Authorizations will be given for medically necessary services only. Forms should be submitted a minimum of seven business days in advance of date of travel.

Travel Request

Medical Professional Information

Member Information

Referring Provider

Accepting Provider

Travel Details

Travel Details

Escort Information(If escort required, Medical Necessity Form is to be submitted with this travel request)

Ground Transportation Only for Member and Air ambulance Request(Only approved for Member when Air Ambulance is requested)

Medical Needs

Acknowledgement

A letter of Medical Necessity and Clinical Documents must be uploaded. If they are not uploaded, the request will be denied and must be resubmitted.

By signing below, I certify that the information provided on this form has been completed by a medical professional and all supporting medical documentation has been submitted with this request including medical necessity forms and/or Prior Authorization Form (PAR)

(Please note, any changes after submitting the request from will cause delays in scheduling of the trip)