The Veyo transportation form, formally the Medical Necessity Form, is a clinical document a licensed healthcare provider completes to authorize specialized non-emergency medical transportation for a Medicaid member who cannot safely use a standard sedan, taxi, or bus. The provider describes the member’s diagnosis and functional limitations, signs the form, and submits it to Veyo for clinical review. Once Veyo approves it, the authorization is attached to the member’s profile and specialized rides can be scheduled at the approved level.
When You Need This Form
Most Medicaid members can call Veyo and book a standard ride without any paperwork at all. The Medical Necessity Form only comes into play when the member’s physical or cognitive condition makes a standard vehicle unsafe or impossible. Veyo will not dispatch a wheelchair van, stretcher vehicle, or ambulance-level transport without an approved form on file.
The form covers transport categories that go beyond an ordinary ride:
- Wheelchair transport, when the member cannot transfer into a regular vehicle seat and must stay seated in the chair. The form asks for the chair’s width.
- Bariatric wheelchair transport, when the member’s weight exceeds the capacity of standard wheelchair vehicles.
- Stretcher transport, when the member cannot sit upright and must be transported lying down.
- ALS or BLS transport, when the member needs continuous monitoring by a certified EMT or paramedic, ongoing oxygen, or life-sustaining equipment during the trip.
The form is also the right tool when a member needs a travel companion, cannot ride with other passengers because they are immunocompromised, or needs to travel beyond Veyo’s standard mileage radius.
Where to Get the Form
Veyo publishes the Medical Necessity Form on its state websites, which follow the pattern [stateabbreviation].ridewithveyo.com. Look under the member or provider resources section. Your Medicaid managed care plan or state Medicaid agency may also host a copy. The form is a fillable PDF, so it can be completed on a computer or printed and filled out by hand.
Veyo runs NEMT programs in several states, including Arizona, Connecticut, Florida, and Virginia, though its contract footprint shifts as states rebid their NEMT contracts. If you aren’t sure Veyo manages transportation in your area, your Medicaid ID card or your state’s Medicaid website lists the current transportation broker.
How to Fill Out Each Part
The form has five parts. Part A, Part C, and the provider signature in Part E are always required. Veyo will reject any form missing medical necessity information, clinical justification, or a valid provider signature.
Part A: Member Information
Enter the member’s full legal name, Medicaid ID number, date of birth, phone number, and street address. Every field is required. The address section also asks whether the pickup location is the member’s home, a skilled nursing or residential facility, or somewhere else. If the member lives in a facility, Part B must also be completed.
Part B: Facility Information
Fill out Part B only when the member resides in a skilled nursing facility, group home, or similar residential setting. It asks for the facility name, a contact person’s name, a direct phone number, fax number, and email address. The email matters because Veyo uses it to send approval or denial notices back to the facility.
Part C: Transportation Needs
This is the clinical heart of the form, and it is where most denials start when the information is too vague. The provider selects the most medically appropriate transport mode from the list: wheelchair, bariatric wheelchair, stretcher, ALS/BLS, livery or medical cab, public transit, or driven by a friend or family member.
Next, the provider checks the member’s impairment categories. The options are muscular or motor impairment, respiratory impairment, cardiac function impairment, cognitive or psychological impairment, and an open “other” field. The provider also indicates what the member cannot do: walk, bear weight, or sit in a wheelchair.
After the boxes, the provider writes a narrative explaining the specific physical or mental limitations that prevent the member from using standard transport. Generic language gets forms kicked back. “Patient is disabled” is not enough. “Member cannot bear weight on lower extremities and requires two-person assist for all transfers” is the kind of description Veyo looks for.
Part C also asks for ICD diagnosis codes and whether the diagnosis is temporary or permanent. That distinction drives how long the authorization will last, so marking it correctly up front avoids a premature renewal cycle.
Part D: Mileage Override Request
Complete Part D only when the member’s medical provider is farther than Veyo’s standard mileage radius, which is typically 10 miles in urban areas and 20 miles in rural areas. Fill in the destination facility’s name and address and select a reason: the closest participating provider is beyond the radius, the member has ongoing treatment at that location, the trip is a surgical follow-up, or the state agency has pre-approved care at that facility. If the extra distance is a recurring need, note that the override should cover the treatment plan rather than a single trip.
Part E: Additional Information and Signature
Part E handles special situations. Check the companion box if the member needs someone to participate in their medical care or help them during the trip, and explain why in the narrative. A general preference for company is not enough; connect the companion’s presence to a specific medical or safety need, such as advanced dementia that prevents the member from communicating with the driver. Minors under 18 are flagged in a separate field, and a parent or guardian typically accompanies them. If the member is immunocompromised and cannot share a vehicle with other passengers, note it here with a written explanation.
The bottom of Part E is the signature block. The provider signs, prints their name, writes their professional designation (MD, DO, NP, PA, or other licensed credential), and gives a phone number or email for follow-up. The form states plainly that it will not be processed if the signature is not from a licensed provider or if the professional designation is missing.
Who Can Sign
Only a licensed healthcare provider can complete and sign the clinical portions of the form. The form itself requires a “licensed health care provider signature and professional designation.” In practice, that means a physician (MD or DO), nurse practitioner, or physician assistant. A medical assistant, office manager, or other unlicensed staff member cannot sign, and Veyo will reject any submission where they do.
How to Submit the Completed Form
Submission methods vary by state. In Connecticut, completed forms are faxed to 860-724-2159 or emailed to ctcc@veyo.com. Other states have their own dedicated fax lines and email addresses listed on the regional Veyo website or on the form itself. The healthcare provider’s office usually handles submission, though the form notes that the member is ultimately responsible for making sure Veyo receives it.
Keep a copy of the completed form and a transmission confirmation, whether that is a fax receipt or a sent-email record. If the submission goes missing, proof of the submission date keeps you from starting over.
What Happens After You Submit
Veyo’s clinical staff reviews the form to confirm the requested transport mode matches the diagnosis and functional limitations. If information is missing or the clinical justification is too thin, Veyo denies the request and sends notice to the contact information on the form. The two most common rejection reasons are missing medical necessity documentation and a missing or invalid provider signature.
Approved authorizations are linked to the member’s Medicaid profile in Veyo’s system. The member or a caregiver can then call Veyo to schedule rides at the authorized level. In Connecticut, the scheduling number is 855-478-7350. Routine trips can be booked up to 30 days in advance, recurring trips such as dialysis up to 180 days ahead, and rides should be requested at least two business days before the appointment. Urgent medical needs and hospital discharges are handled around the clock, though arranging them can take up to three hours.
How Long the Authorization Lasts
Duration depends on whether the diagnosis was marked temporary or permanent. Temporary authorizations, for things like post-surgical recovery or a healing fracture, are tied to the expected recovery window. Chronic or permanent conditions generally get longer authorizations, with 12 months as a common ceiling before a new form is required. For recurring treatment such as dialysis or chemotherapy, Veyo can authorize standing rides for the duration of the treatment schedule, up to that 12-month cap.
Submit a new form whenever the member’s condition changes in a way that affects transport, for example moving from a wheelchair to a stretcher, or recovering enough to use a standard vehicle. A change in functional status triggers a new clinical review even if the original authorization has not expired.
If Your Request Is Denied
A denied form is not the end of the road. Federal Medicaid rules give every enrolled beneficiary the right to challenge a denial of services, including NEMT.
Start with an internal appeal to Veyo or the managed care organization that oversees your transportation benefit. Read the denial notice carefully. It should say what was missing or why the clinical justification fell short. The fix is often straightforward: the provider adds a more detailed narrative, corrects a diagnosis code, or resubmits with a proper signature. If the denial is upheld, you have the right to request a state fair hearing before an administrative law judge. Federal rules give you up to 90 days from the date the denial notice was mailed to file that request.
Accommodations must be provided at no cost during the appeal if you have a disability, including large print, Braille, and sign language interpreters. You can also name an authorized representative in writing to handle the appeal for you.