Health First Colorado members who need non-emergent medical transportation (NEMT) to a provider more than 25 miles from home need this verification for the long-distance trip. It records the member, the medical facility and treating provider, and which of four listed reasons keeps the member from being seen within 25 miles. It is valid for 90 days from the initial visit to the treating provider.
Either the NEMT provider or the treating provider may complete it. It asks for the facility name and address, the treating provider's name and title, a contact phone and a Health First Colorado provider ID or NPI, then the printed name, date and organization of the person completing it.
Download the current version from the source each time; forms change without notice.
Verification Form for Non-Emergent Medical Transportation (NEMT) Services more than 25 miles
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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For the identified member, the form is valid for 90 days from the date of the initial visit to the treating provider. That date is recorded on the form, along with the printed name of the person completing it and the date it was signed.
The form states that either the NEMT provider or the treating provider may complete it. Whoever completes it gives the medical facility's details, the treating provider's name and title, a provider ID or NPI, and the organization they represent.
The closest provider is not willing to accept the member; complex medical conditions prevent the closest provider from accepting the patient; the member moved within the three months before the transport; or there is no other provider within 25 miles of the member's residence.