Kansas Medicaid (KMAP) uses this certification to set the level of non-emergency medical transportation a beneficiary needs. The primary care physician or a designee initials each statement that applies, from walking without a wheelchair (Level I) to being confined to a wheelchair or needing a stretcher (Level II), and certifies that the history and condition were reviewed.
A primary care physician or designee (physician assistant, nurse practitioner or clinical nurse specialist) completes and signs the whole form, printing name, credentials, phone and fax.
Download the current version from the source each time; forms change without notice.
Certification by Medical Provider for Transportation Services
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A primary care physician or a designee: a physician assistant, nurse practitioner or clinical nurse specialist. The signer certifies having reviewed the person's history and condition and that the information is accurate and complete. The form is returned or invalidated if it is not totally completed.
Up to one year or less, unless the box for permanent wheelchair confinement is checked. A temporary wheelchair certification lasts for the expected duration entered, and a new form is needed after that or whenever the beneficiary's level changes from Level II to Level I.
Level I is for beneficiaries able to walk, with or without a walker, cane or personal help. Level II is for those unable to walk who need a wheelchair, including permanent or temporary confinement, and for nonambulatory beneficiaries who need a stretcher.