Connecticut Facility Network

ConnecticutMember Network

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 TitleDescription
Member Information BrochureHow to Access Non-Emergency Medical Transportation (NEMT) for CT Husky A, C and D Medicaid Members
Member Information Brochure (Spanish)Cómo acceso No son de emergencia Transporte médico (NEMT) para CT Husky A, C y D Los miembros de Medicaid
Closest Provider CertificationCPC Form must be completed by your medical provider
Physician Transportation Restriction Form (PTR)PTR form must be completed by your medical physician for
Gas Reimbursement GuidelinesReimbursement Guidelines
Gas Reimbursement Invoice FormGas Reimbursement Invoice Form
Companion Referral FormForm that is used to approve medical necessity for companions and aides
Parental Consent to Travel FormAuthorization form for Children under the age of 16 to travel alone
Parental Consent to Travel Form - SpanishAuthorization form for Children under the age of 16 to travel alone - Spanish
Covered/Non-Covered Service ListList of most common covered/non-covered services for Non Emergent Transportation
How to submit a complaintHow to submit a complaint

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