Intelliride Colorado Forms. 1, 2021, Health First Colorado members who reside outside of the

1, 2021, Health First Colorado members who reside outside of the following counties, Adams, Arapahoe, Boulder, Health First Colorado members are required to travel to the closest medical facility that is able to provide the necessary treatment or services. This form will Forms • Forms can be found at https://transdevhealthsolutions. com Mail: 2222 Cuming Street Omaha, NE 68102 Edit, sign, and share intelliride mileage reimbursement form online. Edit, sign, and share intelliride mileage reimbursement form online. Filling out the Intelliride Standing Updated Jan 2023 Once your trip is completed, you can email the form to claims. for transportation for one of your patients. Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. Access links to the new electronic forms at the bottom of this page in the “Medical Documentation” section – the same place you have accessed PDF forms in the past. All travel beyond 25 miles, will require the Beyond 25 mile . com/NEMT to learn more. intelliride@transdev. rovide any supporting information as needed. Who will take me to my appointment? Fill Intelliride Forms, Edit online. • For mileage reimbursement, clients can submit the following form within 10 business days after their appointment. IntelliRide's toll-free number: 1-855-489-4999; State Relay: 711 Visit HealthFirstColorado. Try Now! Effective Aug. com IntelliRide, LLC 2775 S Vallejo St, Englewood, CO 80110 Mileage Reimbursement Verification Form (Single Trip) Fax: (402) 934‐8622 claims. Email, fax, or share your intelliride mileage reimbursement form form via URL. 8622 or mail it to 2222 Cuming Street, Omaha, NE 68102. o Clients must Call for a ride to your medical appointment. intelliride@Transdev. Please fill out this Level of Service Medical Recommendation Form completely and . com Mail: 2222 Cuming Street Omaha, NE 68102 Mileage Reimbursement Verification Form (Single Trip) Fax: (402) 934‐8622 claims. o Client must schedule trip with Transdev prior to the appointment. Find out what information you need to provide and what to do if you hav Please complete this form and return it to IntelliRide for reimbursement of your mileage within 10 business days of your medical appointment. You can also download, print, or export forms to your preferred cloud storage service. com, fax it to 402. This form will be used to Learn how to schedule a free ride to your health care appointments with IntelliRide or a local provider. Here is how to use the new forms: Access links to the new electronic forms at the bottom of this page in the “Medical Please send completed form to: Fax (720) 302. 0106 | Email: us. com/colorado/member-resources/ • If the individual needing transportation is a minor (under the age of 13) and will be traveling without a Health First Colorado (Colorado's Medicaid program) provides Non-Emergent Medical Transportation (NEMT) and mileage reimbursement for members who Once your trip is completed, you can email the form to claims. 934. No need to install software, just go to DocHub, and sign up instantly and for free. coclinicalcoordinator@transdev. To schedule an IntelliRide ride in Colorado, you may use their dedicated online system or contact customer service directly. Dear Medical Professional: for one of your patients. If you have a friend, family member or volunteer who can drive you to your appointment, Health First Colorado offers mileage reimbursement through IntelliRide. Transdev converted all forms from PDF to a completely digital process. Please fill out this Level of Service Medical Recommendation Form completely and provide any support ng information as needed.

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