Transportation Authorization Form

Provider Demographics

Authorized Provider Authorized Facility

Name: Rene Alejos Name: D Best Transportation Llc
Address: Address: 68594 Calle Prado
Cathedral City CA 92234

Phone: Phone: 760-406-9410

Fax: Fax: 760-262-9422

Pick Up Drop Off

Address:: 401 Alice Lane Address:: 81709 Dr Carreon Blvd

Blythe CA 92225 Indio Ca 92201

Phone: 442-258-0680 Phone: 760-347-0000

Instructions: Will Call
Special Round Trip
Instructions: Ambi - door to door
Approved for additional trips:
4/17/23 - 8:00 AM
4/18/23 - 8:00 AM
4/19/23 - 8:00 AM
4/20/23 - 8:00 AM

Member Demographics

IEHP ID: 20170401011600 Phone:

Member Name: Rene P Alejos DOB: 02/24/1974
Address: 401 Alice Lane LOB: Medi-cal
Blythe, CA 92225 IPA: JJJ 10000012

Authorization Information

Authorization Number: H2309482488

Acuity: Standard Pre-Service
Case Type: Transportation - Ambulatory
NOTICE: This facsimile contains confidential information that is being transmitted to and is intended only
for the use of the recipient named above. Reading, disclosure, discussion, dissemination, distribution, or
copying of this information by anyone other than the named recipient or his or her employees or agents is
strictly prohibited. If you have received this facsimile in error, please immediately destroy it and notify us
by telephone at (866) 725 4347.

Page 1 of 3
Primary Diagnosis:
Service From/To Dates:
Services Approved:
Z81.4 Family history of other substance
abuse and dependence
04/14/2023 To 04/20/2023
T2001 - Nonemergency Quantity: 14.0 Visits
transportation; patient
attendant/escort

Reservation Date/Time Appointment Time

04/14/2023 8:00 AM
Type of Transport Ambulatory
Number of Passengers 1
Authorizing Name IEHP Transportation Team
Authorizing Number 877-761-6248
Service From/To Dates: 04/14/2023 To 04/20/2023
Services Approved: A0425 - Ground mileage, per statute Quantity: 2800.0 Miles
mile

Reservation Date/Time Appointment Time

04/15/2023
Type of Transport
Number of Passengers
Authorizing Name
Authorizing Number
Service From/To Dates:
Services Approved:
8:00 AM
Ambulatory
1
IEHP Transportation Team
877-761-6248
04/14/2023 To 04/20/2023
A0428 - Ambulance service, basic Quantity: 7.0 Units
life support, nonemergency
transport, (BLS)

Reservation Date/Time Appointment Time

04/16/2023 8:00 AM
Type of Transport Ambulatory
Number of Passengers 1
Authorization Name IEHP Transportation Team
Authorizing Number 877-761-6248
Service From/To Dates: To
Services Approved: - Quantity:

IMPORTANT NOTICE!
Upon Acceptance of referral and treatment of the Member, the Physician/Provider agrees to

NOTICE: This facsimile contains confidential information that is being transmitted to and is intended only
for the use of the recipient named above. Reading, disclosure, discussion, dissemination, distribution, or
copying of this information by anyone other than the named recipient or his or her employees or agents is
strictly prohibited. If you have received this facsimile in error, please immediately destroy it and notify us
by telephone at (866) 725 4347.

Page 2 of 3
 accept IEHP Contracted Rates. This referral/authorization verifies medical necessity only.
Payments for services are dependent upon the Member's eligibility at the time services are
rendered.

Criteria utilized in making this decision is available upon request by calling IEHP at (800) 440-4347.

*For Members who have dual medical coverage, IEHP is always the secondary payor.

Disclaimer: This is an authorization for services, not for payment. All standard coding rules will
be applied upon receipt of the claim.

NOTICE: This facsimile contains confidential information that is being transmitted to and is intended only
for the use of the recipient named above. Reading, disclosure, discussion, dissemination, distribution, or
copying of this information by anyone other than the named recipient or his or her employees or agents is
strictly prohibited. If you have received this facsimile in error, please immediately destroy it and notify us
by telephone at (866) 725 4347.

Page 3 of 3