MassHealth pays only for medically necessary nonemergency ambulance and wheelchair van transportation, and this two-page form documents why the member needs it. It records the trips, dates of service, pick-up location and destination, then the specific wheelchair van or ambulance criterion the member meets. The transportation provider keeps the completed form for six years from the date of service.
The transportation provider is responsible for completeness and fills in the trip, member, location and provider sections. The requesting provider checks the criteria in Section 6a or 6b and signs Section 7: a physician, PA, NP, nurse-midwife, dentist, psychologist, managed care representative or physician-designee RN.
Download the current version from the source each time; forms change without notice.
MassHealth Medical Necessity Form for Nonemergency Ambulance/Wheelchair Van Transportation
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
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A MassHealth-enrolled physician, physician assistant, nurse practitioner, nurse-midwife, dentist, psychologist or managed care representative with adequate knowledge of the member's condition. A registered nurse may sign as a physician designee if supervised by an enrolled physician, whose name and NPI go in the designee block.
Recurring transportation can only be authorized for up to a 30-day period, beginning with the date of the first trip. The form records the number of trips requested, the dates of service and the medical service the member receives at the destination, along with the pick-up and destination details.
No. The PT-1, Provider Request for Transportation, is submitted through the MassHealth Customer Web Portal to arrange other transportation. The MNR-NAT documents why the member medically needs an ambulance or wheelchair van, and one wheelchair van criterion applies when PT-1 transportation is unavailable or inappropriate.