Provider Forms - Various Consumer Related forms for MATP Providers

• HIPAA Authorization for Use or Disclosure of Health Information
  Consumer completes at the time of registration.



• MATP Policy Acknowledgement
  Consumer initials upon receipt of MATP policies.



• Mode of Transportation Determination
  Consumer and Grantee complete at the time of registration to determine the least costly and most appropriate mode of transportation that will meet that individual consumer’s current level of mobility and functional independence.



• Mileage Reimbursement
  Consumer Form used for reimbursement for costs incurred for mileage, parking and toll when a private vehicle is used for transportation to medical appointments.



• Incident Report
  Grantee completes within 48 hours of an incident involving the consumer and/or other individuals.



• Written Notice
  Grantee issues to consumer when services are determined, changed, denied, suspended or terminated. The notice informs the consumer of their right to appeal.



• Transportation Referral
  “Referral Form” (Form must be downloaded/saved before completing)
  
  
  • CAO Resource Accounts
    County Assistance Office Email Addresses including districts.
  
  
• SeGov User Registration and Change Forms
  Server Registration and Change Forms to access to the SeGov portal.

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