1135 S. Victor Ave, Tulsa, OK 74104
P: 918-794-0088 | F: 918-794-0631
COVID-19 Referral Criteria
Letter of Medical Necessity
All medicaid patients are entitled to receive Non-Emergency Transportation services to include meals, lodging, and transport as mandated by federal regulation 42CFR440170. To be eligible to utilize these benefits, medical necessity of the patient's treatment at your facility must be documented to support the request. However, not all medicaid patients who apply will meet the state criterion set forth for approval. While mileage is not the only determining factory, typically patients are eligible for this benefit if they reside more than fifty (50) miles from the medical facility. DHHS Review Board will take into consideration ALL requests that are under the mileage criterion based on the circumstances from the narrative you provide below. All information in this document is confidential and must by handled in accordance with HIPAA regulations.
I certify that it is necessary for this patient to receive treatment at the above facility and other requested services.