Transportation Authorization Form

Provider Demographics

Authorized Provider Authorized Facility

Name: charlotte dudley 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:: 27454 Powder Ct. Address:: 255 E Bonita Ave

Menifee CA 92584 Pomona Ca 91767

Phone: 951-289-8101 Phone: 909-596-7733

Instructions: Wait and Return
Special Roundtrip
Instructions: Gurney ht 5.6 wt 304

Member Demographics

IEHP ID: 20050100162200 Phone:

Member Name: Charlotte D Dudley DOB: 01/01/1985
Address: 27454 Powder Ct. LOB: Medi-cal
Menifee, CA 92584 IPA:

Authorization Information

Authorization Number: H2309444702

Acuity:
Case Type:
Primary Diagnosis:
Service From/To Dates:
Services Approved:
Standard Pre-Service
Transportation - Gurney Transport
R68.89 Other general symptoms and
signs
04/10/2023 To 04/10/2023
T2005 - Nonemergency Quantity: 2.0 Visits

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
 transportation; stretcher van

Reservation Date/Time Appointment Time

04/10/2023
Type of Transport
Number of Passengers
Authorizing Name
Authorizing Number
Service From/To Dates:
Services Approved:
2:30 pm
Gurney Transport
2
IEHP Transportation Team
877-761-6248
04/10/2023 To 04/10/2023
A0380 - BLS mileage (per mile) Quantity: 112.0 Miles

Reservation Date/Time Appointment Time

Type of Transport Gurney Transport

Number of Passengers
Authorizing Name
Authorizing Number
Service From/To Dates:
Services Approved:
IEHP Transportation Team
877-761-6248
04/10/2023 To 04/10/2023
A0420 - Ambulance waiting time Quantity: 2.0 Units
(ALS or BLS), one-half (1/2) hour
increments

Reservation Date/Time Appointment Time

Type of Transport Gurney Transport

Number of Passengers
Authorization Name
Authorizing Number
Service From/To Dates:
Services Approved:
IEHP Transportation Team
877-761-6248
04/10/2023 To 04/10/2023
A0424 - Extra ambulance attendant, Quantity: 2.0 Units
ground (ALS or BLS) or air (fixed or
rotary winged); (requires medical
review)

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