Forms
First Transit's fax number is (630) 873-1450.
- Revised 01/31/19, HFS 2270, Physician Certification Statement (PCS) for Ambulance Transport or
Medicar /Service Car Transport (replaces the current MCA and CTS forms) - 02/15/19 Notice to Enrolled Transportation Providers; Hospitals; and Nursing Facilities regarding HFS 2270
The HFS 2270 Physician Certification Statement (PCS) form replaces the current Medical Certification for Non-Emergency Ambulance (MCA) and Certification of Transportation Services (CTS) forms. The new PCS form is an important document to certify that the appropriate level of transportation is being requested and is necessary for payment and/or verification of the adequate level of service. This applies to participants covered under fee-for-service Medicaid, as well as HealthChoice plans.
You may begin using the new PCS form effective immediately to replace the current MCA and CTS forms. The transition period will and become mandatory on April 1, 2019, when the MCA and CTS forms will be phased out.
- Standing Prior Approval (SPA) Form
- Single Trip Form
- CTS Form
- Online MCA Form (it will generate a one-page PDF copy for your records after you click Send)
- MCA Form (pdf) (please use only if you are not able to submit via Online MCA Form)
- Psychiatric Services Treatment Plan Form for CAP/GAP Providers
- Psychiatric Services Treatment Plan Form for Provider Type 36 (LPHAs)
- HFS 3701T Therapy Prior Approval Request Form (if you are unable to view this form, right-click to save the file and then open it in Adobe Reader directly)
- Complaint Form
