Modivcare Medical Necessity Forms in 2027: Each State's Form, Who Signs, and Where It Goes

Modivcare books the most cost-effective ride that fits each Medicaid member. A member who can walk to the curb rides a sedan, and a member near a bus line may get a bus pass. A medical necessity form is how a clinic, hospital, or nursing home tells Modivcare the rider needs more, and how your wheelchair or stretcher van ends up on the trip.

What a Modivcare medical necessity form decides

Modivcare’s Mississippi provider manual (February 2024) says medical necessity paperwork from the member’s medical provider is generally required for every wheelchair, stretcher, and ambulance ride, and that Modivcare’s prior authorization staff coordinate getting it. Across the states it serves, the forms fall into three groups:

• Level of service forms move a rider up to a wheelchair van, stretcher, or ambulance. Delaware, Oklahoma, South Carolina, and Virginia call theirs a Level of Service Certification of Medical Necessity.
• Restriction forms excuse a rider from the bus or from a ride with family. Florida, Michigan, Oklahoma, and Philadelphia’s program call theirs a Physician’s Transportation Restriction Form, and South Carolina uses a Mass Transit Rider Form.
• Distance and attendant forms approve a long trip to a faraway specialist or a second person on board.

Not every rider needs one. Michigan has required its form only for Medivan and wheelchair service since February 1, 2020, and New Jersey asks for one from a curb-to-curb ambulatory rider only when the rider wants to move up from the bus. For how these forms work across all programs, not only Modivcare’s, see the medical necessity form entry.

Which form each state uses

Modivcare posts a separate form for each state on its facility pages, and each form names its own fax line. As of October 6, 2026, these are the forms for programs Modivcare still runs:

State and program	Form	Send it to
Delaware Medicaid and Delaware First Health	Level of Service Certification, wheelchair and stretcher	Fax 877-813-5599
Florida fee-for-service Regions A, G, H, and I, plus some plans	Verification of Medical Transportation Abilities; Physician’s Transportation Restriction Form	Fax 866-779-5242
Hawaii, HMSA QUEST	Medical Necessity Form (July 3, 2025)	HIExceptions@modivcare.com or fax 866-475-5745
Maine, MaineCare outside the Penquis counties	Certification of Medical Necessity of Mode of Transportation	Fax 877-637-9091
Michigan, Wayne, Oakland, and Macomb	MDHHS Medical Necessity Form; Physician’s Transportation Restriction Form	Fax 866-569-1910; restriction form fax 866-569-1906
New Jersey, NJ FamilyCare	Three MNFs: mass transit and ambulatory, wheelchair and stretcher, specialty care	Fax 877-457-3316
New Mexico, Presbyterian	MNF for trips over 120 miles; attendant certificate	Fax 866-402-0522
Oklahoma, SoonerRide	Level of Service Certification; Physician’s Transportation Restriction Form	Fax 866-697-0497
Pennsylvania, Philadelphia MATP	Physician’s Transportation Restriction Form (June 24, 2022)	Fax 877-835-7432
South Carolina Medicaid	Level of Service Certification for stretcher (August 28, 2025); Mass Transit Rider Form	Fax 877-601-0530
Utah Medicaid	Physician’s Certificate (February 4, 2025); MNF for trips over 75 miles	Fax 877-637-9079
Virginia, Sentara and Humana plans	Level of Service Certification	Fax 866-885-3788
West Virginia Medicaid	Level of Need Assessment Form (February 9, 2022)	Fax 855-882-5998

A few notes on that list:

• Florida. Which health plans still send rides through Modivcare changes often. The Modivcare in Florida page tracks them.
• Fax lines. Use the number printed on the form. A state’s standing order and trip request forms can print a different one: in Oklahoma they go to fax 800-597-2091, and in Virginia to fax 866-907-1491. Modivcare’s New Jersey and Delaware pages also list fax 866-457-3316 and fax 866-813-5599, where those states’ forms print fax 877-457-3316 and fax 877-813-5599. If a fax does not go through, call the facility line on that state’s page.
• Oklahoma. OHCA’s SoonerRide page still names LogistiCare Solutions, Modivcare’s former name, as its partner. OHCA’s June 2026 board packet asked for a 90-day extension of the old contract through September 30, 2026 and for funding of a newly awarded NEMT contract from October 1, 2026. It does not name the new holder, so ask Modivcare which form and fax line apply before you rely on them. The Modivcare in Oklahoma page tracks the change.
• California. Modivcare’s California page holds a separate Physician Certification Statement for several Medi-Cal plans, among them Alameda Alliance, Anthem, CalOptima, Health Net, and San Francisco Health Plan. See the Medi-Cal PCS form guide.
• Arkansas. Modivcare’s Arkansas page, updated in April 2026, says no medical necessity form is required for a wheelchair ride at this time, though Modivcare may call the medical provider to confirm the need. See Modivcare in Arkansas.
• New York. Medicaid rides there use Form-2015 through the state’s own manager, not Modivcare. See the New York transportation abilities form. The form on Modivcare’s New York page is Healthfirst’s Medicare form for repeat non-emergency ambulance trips (0208-26).
• States that moved on. Modivcare’s site still lists forms for Iowa, but Iowa HHS names MTM Health as the broker for fee-for-service and all three plans. Virginia fee-for-service moved to MTM Health on October 1, 2026, and Blue Cross and Blue Shield of New Mexico moves its Medicaid rides to MTM Health on November 1, 2026. Those riders need MTM’s form instead: see the MTM level of need form.

Who can sign and how long a form lasts

The clinician who signs must hold a title the state accepts, and the length is the box that clinician checks. Here is each form’s rule:

State	Who can sign	How long it lasts
Delaware	Attending physician, PA, or RN. The state page adds NPs and clinical nurse specialists	No period on the form
Florida	Physician (with NPI) or a licensed professional who can certify need	Restriction form: 30, 90, 180, or 365 days
Hawaii (HMSA)	Physician, PA, nurse practitioner, or health care coordinator	Until the date written, or permanent
Maine	Physician, PA, nurse practitioner, or psychiatrist	No period on the form
Michigan	PCP, specialist, PA, NP, CNS, midwife, RN, social worker, dentist	90 days, 6 months, or 1 year
New Jersey	Doctor, PA, nurse practitioner, or registered nurse	90, 180, or 365 days, or lifetime
New Mexico (Presbyterian)	Attending physician, PA, or certified nurse practitioner	120-mile form: 12 months or another period. Attendant form: 90 or 180 days or another period
Oklahoma	Attending physician, physician assistant, or registered nurse	This trip, 30, 90, or 180 days
Philadelphia	Treating physician	6 months, an end date, or permanent
South Carolina	Physician, NP, or PA; a registered nurse for one trip only	Up to 90 days
Utah	MD, DO, doctor of physical therapy, PA, NP, or RN	Stretcher: 3 months. Otherwise an end date or permanent
Virginia	Attending physician, physician assistant, or registered nurse	60 days, 90 days, or ongoing
West Virginia	Physician, PA, nurse practitioner, or RN who treats the member	An end date or permanent

Florida’s Verification of Medical Transportation Abilities works on the same idea with different words: the clinician marks the need temporary until a date, long term for up to a year, or permanent, and must tell Modivcare if the rider’s condition changes.

Forms that excuse a rider from the bus

Restriction forms exist because Modivcare sends many members to public transit first. The distance that triggers it differs by state:

• Florida and South Carolina. Members whose pickup and drop-off are each within a quarter mile of a bus stop get bus passes or tickets. On Florida’s abilities form, a yes to mass transit means the rider can walk up to three quarters of a mile.
• New Jersey. Mass transit members must ride the bus to every appointment within half a mile of a stop.
• Hawaii and West Virginia. The forms ask whether the rider can walk half a mile.
• Michigan and Philadelphia. The restriction forms ask whether the rider can walk a quarter mile. Philadelphia’s form is not accepted without a medical reason for paratransit.
• Utah. The Physician’s Certificate lists the order Utah Medicaid uses: mileage reimbursement, then the bus, then paratransit or dial-a-ride, then Modivcare, then the state for ambulance.

Several forms have a middle answer: the rider can take the bus only with a companion. Modivcare’s forms in Michigan, Oklahoma, West Virginia, and Hawaii say it then pays the companion’s fare but does not supply the companion, and Philadelphia’s form says it pays the fare.

Long trips and attendants

Two states use a form for distance, built on the rule that Medicaid pays for the trip to the closest provider who can give the care:

1. Utah, over 75 miles one way. The referring physician, or a nurse practitioner, physician assistant, or certified nurse midwife, signs the form for one specialist. Each specialist farther than 75 miles needs its own form. It must reach fax 877-637-9079 within four weeks of the first visit, or rides to that facility are denied. Utah’s manual (July 2026) allows up to four weeks of rides while the form is completed or care moves closer.
2. New Mexico, over 120 miles for Presbyterian members. The form lasts 12 months. If the clinician marks the trip not medically necessary, the member cannot schedule it. The Modivcare in New Mexico page covers the rest of Presbyterian’s ride rules.

New Jersey adds a Closest Provider Certification for long trips, explained on the Modivcare in New Jersey page.

Attendant forms decide whether a second person rides along:

• Utah. If the Physician’s Certificate says the rider needs an adult companion, every trip requires an escort until a physician says in writing that it no longer does. A parent can name up to two adult attendants for a child on a separate form, and each must show the driver a photo ID.
• New Mexico. Presbyterian members 18 and older who want an adult attendant need the attendant certificate, good for 90 or 180 days.
• Virginia. The Attendant Care Eligibility Assessment asks about self-injury, aggression, and incidents on past rides, and goes to fax 866-907-1491.
• Delaware. A parent signs a Statement of No Alternative Transportation with a child’s standing order. If the family has a car but needs it to get to work, the parent attaches a work schedule.

How an attendant changes your trip is covered in escorts and caregivers.

Why forms get sent back

New Jersey’s guidelines, reposted in April 2026, give the most detail on what Modivcare rejects. Most of it applies to every state:

1. A blank field. New Jersey returns incomplete forms, and Utah’s Physician’s Certificate must be 100% complete to be valid.
2. The name only on the fax cover. The member’s name and date of birth must be on the form itself.
3. The wrong signer. New Jersey refuses telephone orders and signatures by unit clerks and licensed practical nurses, and the printed name must match the signature.
4. More than one level checked. Pick one level of service.
5. A diagnosis without function. Serious illness, injury, surgery, end-stage renal disease, and dialysis do not by themselves qualify a rider for a higher level. Describe what the rider cannot do. New Jersey and West Virginia ask for words, not diagnosis codes.
6. Weak stretcher proof. New Jersey wants bed confinement shown, not just written, with the rider unable to stand or pivot without help, unable to walk, and unable to sit in a chair or wheelchair. Pressure ulcers on the sacrum or buttocks must be stage 3 or worse, morbid obesity alone qualifies only at a BMI of 80 or more, and pain must rate 7 to 10 despite medication. South Carolina’s form describes a rider confined to bed who cannot sit in a wheelchair and needs no medical monitoring on the trip, and the clinician must describe the physical condition that makes a stretcher necessary.

What your company can do about missing forms

You never sign these forms, but missing ones cost you trips. Without Michigan’s form, Modivcare will not book door-to-door or wheelchair service for the rider. In Utah, the rider gets four weeks of trips and then stops.

1. Check the level on every trip. Modivcare’s Mississippi manual requires you to contact Modivcare immediately when you think a rider was booked at the wrong level, through the 24-hour transportation provider line. It also says a wheelchair user who has no wheelchair is not upgraded to stretcher.
2. Track end dates for regular riders. Florida’s form says a temporary or long-term approval is valid only for the period marked, so ask the clinic for a new form before a regular rider’s date passes. Utah does not ask for a new form at each three-month standing order review unless the rider’s mobility changed. A standing order is its own form with its own fax line: see standing orders and the Modivcare standing order form.
3. Ask early at discharge. South Carolina requires its stretcher certification for every stretcher rider. A registered nurse can sign one that covers a single trip, while a physician, nurse practitioner, or physician assistant can certify up to 90 days. See hospital discharge transportation.
4. Tell facility staff where the form goes. The fax line differs by state, and a form sent to the wrong state’s line does nothing.