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Duplicate Detected

Separate funds will not be authorized for a second trip from the same household on the same day. Medicaid transportation funds are only available when no other resources are available. Another member of the household traveling on the same date to the same location is considered a resource. Per the Administrative Rules of Montana (ARM) section 37.86.2402 (9) "Coverage of transportation is limited to the least expensive mode of transportation suitable to the recipient's needs plus any applicable per diem."

You will not be able to submit this request with the current data as it has been detected to be too similar to an entry you provided. Please double check what you've entered and call 800-292-7114 if assistance is required.

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*Phone Number:

*Patient Medicaid ID or SSN:

*Patient First Name:

*Patient Last Name:

*Date of Birth:

*Physical (Pickup) Address:

*City:

*State:

*Zip:

*Travel Mode:

*Driver's Name:

*Transportation Provider:

*Does the driver have a valid driver's license?

Yes

*Is the patient (or the driver) excluded from receiving federal health care?

Yes

*Medical Provider:

*Destination Address:

*Destination City:

*Destination State:

*Destination Zip:

*Appointment Reason:

*Appointment Time:

Referred By:

Additional Notes:

CANCEL