HomeMy WebLinkAbout9.25.19 LogistiCare Transportation Information - Kennelly, Scott Waugh, Melanie
From: Kennelly, Scott
Sent: Wednesday, September 25, 2019 2:26 PM
To: BOS
Cc: Kim, Sang
Subject: LogistiCare Transportation Information
Attachments: Anthem - LogistiCare Flyer ENG.pdf; Anthem LogistiCare Flyer SP.pdf; [AH8N
LogistiCare ENG.pdf; CAH&W LogistiCare SP.pdf; CHWpcsform.pdf
Good afternoon Supervisors,
We have been receiving feedback from members of the community that transportation is a serious hardship for many
low income people in Butte County. A significant number of people who have MediCal do not have a vehicle or extra
money for gas or bus passes.This creates problems for those trying to attend necessary medical, dental, substance
abuse appointments, a pharmacy, or ongoing care with health care providers such as for dialysis.
I wanted to share with you all a resource called LogistiCare for anyone with Butte County Medi-Cal (either Anthem or
California Health and Wellness). Logisticare is free and is a transportation service that will take anyone with one of these
two plains to and from scheduled appointments.There is no cost to the client nor is there a limit to the number of times
transportation is utilized.The only requirement is that they are given 5 days' notice to schedule the driver.
I have discussed this information with some of you but wanted to be sure you all had something in writing to reference.
Please feel free to share these attached flyers with your constituents.
Thanks,
Scott
Scott Kennelly L.C.S.W
Interim Director
Butte County Behavioral Health
CONFIDENTIALITY NOTICE: This e-mail transmission, and any documents or messages attached to it, may contain
confidential information that is legally privileged. If you are not the intended recipient, or a person responsible for
delivering this e-mail to the intended recipient,then you are (1) notified that any disclosure, copying, distribution,
saving, reading or use of this information is strictly prohibited, (2) requested to discard and delete this e-mail and aniy
attachments, and (3) requested to immediately notify us by e-mail that you mistakenly received this message
skemne|Uy@buttecoumty.net<mai|to:skenne|8y@buttecomnty.net», fax (S3O) Q9S-6549, ortelephone (S3O)8Q1'285B.
Thank you.
1
A 1 I them. 0A„,
11
,
•
BlueCross 3,
You're 1 0 illIng
1 ' 1''' (1') 1111 ljj'! I) gjj.11/1.1 jjj jjJ j jj )jj"j iiij'j JJ'‘, 1
rl jj ljj 'jj?'( Jijjjj(J1j jjljJj li i '; JJ [j LjJJ J ) 1J J'J "/ I J
CCS ,
Trouble getting to the doctor To get a ride:
should never stand between
business- ay
1. Call Anthem Blue Cross Transportation Reservations at
health. We 1-877-9314755 at least 5
you and your
not including the day you call, weekendsholiyouraysappointment,.
sbeforeord
work with LogistiCa re to
help you get to your health
2. Give the member ID #listed on your member clDcea
rd
' trnents. 3. If it's your first time
calling, give your primarydoctor's. name,
care appointments,
ypohuonaereavniditfainxgnaunmdbheisrso. rher address. care
You must also give the name of the doctor
wviiw.anthem.comicaimedi-cal
1011110
, 100.0, ii 1 1000000, 0 1, , .
il 01,111„
p till
,,, 14011
,, ,,„„ ,,,,„,,1, 1 0 1
'4',"'1 ',11*1
,,, , HI 141 41 1,1111 1 r III ir 0111 1 111,14 r 1 1 1 III n n„iinr r
i 1 1114 Ailli 4 II 111111111111j
j j 111111 jlj' " I ill jjjjjj Ill 11111111111111111mMh1111111111,111111,11,1111 1116r hi, lihrhi,,,„1 7,, ,,,,,,\,,,,,,,,hx,, ,A4,,,fli,,,11111 ,„„
0 , 1111 I I,
1011111.\,11 ,I , II
. . 1111,104' -,1 111,11111,1111.11
(
„
,
'"ii'\','',1101111111111111
r„,tlt,c,r 1111 11111 II loolior * io,
,k/,ur p,4 irr11r)rrr'„r
, 11111110000100ivolioilovih
1 1 0100000011111111111111111101000000 01 I, ,i i , 01 1 00
11,4°Jo ,00 ,... 11 10'0, 00001 00
0111111,1,111,111101,110011111111°110100001,101 '„,,
1"(P6''''''0000m0010m A , 11111 011 0 1
110 I I'1 111 ''''//11 000000 noi„,,
00000000000000000000000000000,0000000000„,ohdoR01,
4'1,010900drlw„„„„,,, 1 „ 1 1 1 01,11 0 Ilmm111,11 001100 '00 04,( ..,000 1 ', 00100111 10 '1'00i0,0
11111111111 1000 10, 001
00000000100000000,000000000000
0, 1" 0 ' 1 .
001111'04,
oil 1 I hi,1 1 1011 111 1 0001111111 00 1 0 11,1001 111 0 001
1 00 iv 000 0„10 1 1000000 1
000 100000 0 0 0,
1, II 11 1,1 1„„011111„11 10 100 tiLii,011 I 1 I
1 Jill 1,4%1'1 1 Ivy 1 III 1,,
1 1 I 1 III ii,
111111 1111 omm 1, y
1 111, 4i 14 diou 1,111 11000‘k,,,,,III, INI(J)ii,ii)11((
I ily 110001 40 4,e„mloc,HI
1110011111h II 1 11111
',°111,11111,1 111,111111L1L111111
1h111110011111111111111111111010110 I iiiiiiiiiiii,00101001100111111 oilloolua
II IIIIIIIImmhill1111111111111ffiffilimm 111111ii ,,
limi mil 1011,11,)‘01111111110110
iffiliiIIII l'1%
hiIf you live in Los Angeles, call us at 31. 888-2 - .
11„11
Were available All others should call - 888-757-6034).
Pacific time. „ 1
p.m.
Monday through 'd from 7 am,to 7 P
,
A.111. em "
BlueCross.
We can translate this at no cost Call the customer service number on your member ID card. English
Podemos traducir esto gratuitamente. Llame al ntimero de servicio de atencion al cliente quo aparece en
su tarjeta de identificaciOn (ID Card). Spanish
.10 ãU ,714 at.tgal F11.4.1.,11 ro.i,,eJ. I Arabic
LibIJR,Liwpnri tb12 Ulf('tutaliSiup rawnqdwItibu Liwpnq ti2 htnwruouk lwdwrunpnlibrip uwww.uplidwli pwalipb,
nfirl farm° LID quilIRlbphtiRlingaltuti Rwpui (ID) gpw: Armenian
flirMtMlit2DIVEtAi;IVIP - iri#11rifisiD-P±MPAIAZIMMANWP:f.f.V14,&
Chine
,,.à.11.; (ID)z,ti ajLa./ 3al-S-20) 0,..o La Ferri
Peb txhais tau qhov no pub dawb, Hu mus rau qhov chaw pab neeg tus naj npawb xov tooj nyob
rau ntawrri koj daim ID ua rnej zeej. Hmong
sulmimunimantminuctligiut 1 rpqralqtrtiforiuutligigq18 rilutilliStilf3MitcrItkf,1 ID ILICtitiri 1 Khmer
AiNE 0131,5 tliq611 E Dnuci. )1ZIAI ID 31i,011 114 MUI tw,12. Korean
Mbl momem nepeeecry 3TO 6echnanio.iiO3BOHMTe B OTABIl oficripkvieamisi yLiacrilmoe nriawa no HOMBBY,YK8381-1HOMY
B Elmira')Kaplo'4Ke riacTHIKka nnaHa(ID Card), Russian
Maaari namin itong isatin-wika nang watang bayed. Paki tawagan ang numero ng customer service
sa inyong ID card na pang miyembro. Tagalog
Chtlng ted co the phien dich van ban nay mien phi. Xin gqi van phong dich vu h$1 vien qua se din
thopi ghi ten the ID(the hi vien)cua quk vi. Vietnamese
Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and B ue Cross of California Partnership Plan,
Inc.are independent licensees of the Blue Cross Association.ANTHEM is a registered trademark of Anthem insurance Companies,
Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association.Blue Cross of California is contracted with
L.A.Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County,
1 e 1 11„ 1 (76.91
BlueCrass m
ill' •
111 bI b b)/ 1)0 ,,,,, r Ii IIII) 1(ibbIbr (I, bb) 1 b) '10h,,h)h,,I II 111( III b 0/1011 b,1 111111 b /, 1h),/, bb , 1h 0 b,) II bb I r
)b 1
Los problemas para trasladarse Para obtener traasporte:
hasta la oficina del medico 1. i.lammeaa Al-n8t7he7-mB1l-u4e7C55at
msTreannoss5 dias hables antes
Transportation,,Re.si Reservations
nunca deberian ser Lin obstaculo nt:iro93
cita, sin indult'el dia qua llama, los fines de semanas niesu
los
para que usted cuide de ski dias feriados.
.
deiembro.
salud.Trabajamos junto con 2. fPigroupraorecniosnuetealrinerut'amdeero de identifi.c,acion de miembro que
, identificacton m
LogistiCare para ayudarle a
3. Si es la primera vez que llama, P
. ,
dtco de
obtener transpoi-te para que ntJ'maro de telefono y at ni:imero de fax de su me
roporcton
' e el nombre, el
.
asista a las vitas medicas, cuidado prirriario.Tamb . ,proporcionar el nombre
del medico al qua. vera yiesnutdlIrneeccciluoan
r110,111
i 10011,1,, ,r,
www.anthem.com/caimedi-cal
1,H11,1111111111111111111,111011, III ill
lorilili 1
, 11"01 II 1 ,,Ailik,01
,Il ill„ di' wo' 0.1011, 14,j 1001,,,00,
1 000000
,HI il
N d I II 11 dilill 1 1 I I V ,
,Nil 11 .114' , I II NI III I\ 1'11'1 11 1 11 1 1 IN I 1 d N1, , 11 4 11111111111 )1, l'1/111
1 "dd/ 11 1011110
I /d • I .lic ,.., 'NS, lim II N111111111,,,,.Nipii ,,,,, 1111 11 A, 11111N11(1111. 111111
11111111 11 1 1111111111111 of, 1 1 imm I 1111 III, Iiii,i+,10111i1(,i i 11d, )-07/.. ,,, 01,i)), 1,
hook \„,\,,,, 1 1, 1111111 II yill'ill 0D %,,,, ,it Tf',
or, 0
1111 1;1 v ,,,,,f1A1111 11 ivl 10 0 ,,,1,1,1w,„,e 1),t
1 101 111 1 1rJ11N1 ,,
I 111 dd1111# 1115N„,a,14 10111111111111i1144 ' 1 ))1(1111,111 1110100i NI, I 1111 ulle
111110100N N N1 1
1111 ill i
1 II 1 ,,, 4,71 4110,114,,01, 0 , oli
411
d)
I MI,10111, 1 ,
( 1,,
' 10,0,,,,,,,001100 100101w " It'r1lopolii
,
,,,,,1, 1 , d u 1 e'1 1 111111111111111111111111 rid. ,11•,.. ,/ 11
1111111p i i1111 Ni Illilr'111,j',111111111,1 OLIN 11111 iihN 1 11 1111 II 1 1 ,i
1111011 III 01i111, / 1111111 1
ON0101111111110000000000000000001\I
))1'111111'11111111111111111111111111111111111111111111111111111i 1,11,4 AI 1 b 101 III IIIIII 111)1 ri III II irrIbbibbb b, 1,1 I lb" 100001 r ,, /11 h 1
01)))))00)
10 100 oh)) )1
1 I 11 1 III 1 1 bb 110 11 lb, b , b I))1001
, I 11111 )01) ,,1b , 1 1 1 1 10 1 1))),b 1, 11111111111 1 I.('' 1b1101 II 1111111111 11/10
1100001 1 I bribribrir 11 III
1011
6Pregr' Uri as. II , 14
4J 1,11.1111111111111 1111111111111111111111111 1, , il,„„,...,_____
Si viva en Los Angeles' liarileri°s al111141-5•6° '6°17801..(TT,,Y117_181,a,,,tr,u*_407..4527 ,,1
Las personas que resi.dati en otro jugar., deberi ilamar a
CITY 4) E."stari-los disponibles de Junes a viernes,
flora del Pacifico. 1 1
Hylmill, 111,1111111111H1,11111111111 1 iii,110 $',,,, 0 1
A(),,,At,,KT1.011j1,111;b17 St.' 1111 11711) IIIII
" nthem trkki
11
BlueCross
We can translate this at no cost.Call the customer service number on your member ID card. English
Podemos traducir esto gratuitamente. Liame al numero de servicio de atencion al cliente que aparece en
su tarjeta de identiiicacion(ID Card). Spanish
,ID0-1-a,,,r014"1'La-L.••Mpt...1-2411, '.141-v 414,44u-0 Arabic
Llibbp tpupnq VI,Jp wju wl.apiwp lawpcplwbk:Liiwpnq 1n2 htnwruouti jwdwrunpribbpri miumwritplwli
npb r?inQ Lia cpraibg dbp plletinLialwb Rwptnp (ID)Lipw; Armenian
tn17111-3.tERAZIR 3:30*. Ifig111931D- ±FfiNfiNNIAMAIMPf21114111:: Chinese
(0) ..'L;a--C La 0.*rira aJLa-Za 1.3-1, a-a-a•t;01-14-tIj dq cog Farsi
Peb txhais tau qhov no pub dawb. Hu mus rau qhov chew pab neeg tus nal npawb xov tooj nyob
rau ntawm koj dairn ID ua mej zeej. Hmong
ttailintitiniligiStrilWailiagfpg 1 CtpliCiktgliliritalhtliS MUttlin11801.611(41 ID rndiiri i Khmer
tt Mil E 21C--,WC1. 210X11 ID 31 :701121EL.--: 224 MHI OILIA12. Korean
Mbl mormem nepesecni 3TO 68aUlaTHO.iiO3BOHNTO B°win o6criptcHaaHi1a riaCTHIIKOB nnaHa no wimpy,ylia3aHHONly
a smell Kap-roLiKe riac-rnwa nnaHa(ID Card). Russian
Maaari namin itong isatin-wika nang walang bayed. Paid tawagan ang numero ng customer service
sa inyong ID card na pang miyembro. Tagalog
ChOng toi ce th6 phien dlch van ban nay ran phi.Xin gyi van phong dich vy hI vien qua s6 digin
thdal ghi tren the ID(the hi vien)cue quy vi. Vietnamese
Anthem Blue Cross es e nombre comercial de Blue Cross of California,Anthem Blue Cross y Blue Cross of California Partnership
Plan,Inc.son licenciatarlos independientes de Blue Cross Association.ANTHEM es una ma rca comercial registrada de Anthem
Insurance Companies,Inc.El nombre y slmboio de Blue Cross son rnarcas registradas de Blue Cross Association,Blue Cross of
California tiene contrato con LA.Care Health Plan para brindar servicios de Medi-Cal Managed Care en el condado de Los Angeles.
lh'1.'1)i?'''n'nliiilinnif I
Y,'onn,n'ilinnn Inn:1111,Y !inn:1'0,(In'ol",,In,,,n11111'n,,111,,:n'n,nnInonly n nt,',I'l ,,A,in,, ,n,en:,'1,1!,!,11,,u n,Ilin nr,,n,l,',Y111,',1 nv,,Inillin',117in,,111,11111100000,1001100!„1„1111111111111111
11',Inn nin Inn Inn,111,,,,n,n1InInt II u 11111,11:1',',,1111„n111,1„nninn nn,n,n011,11,,,,,'Ily In y,,1,',1,111n,,n!Odle 11,,nnI,V,'inn yinn:nn,,n,nin,'n 1 n,11,11 1,,,,n'n,1 Inl 'nn,,n11'nli'n1,1,1111,,,n1.1,11',,,,',',,', ,,,,1,'„„n n nun'nn'n tInn, ''n lin„1",11,4.1'1'111,,Ild,,11„1, ',,,,,,,,,,,nnunnnlInnn9gin,,,,r'I,/'
1,'Innl,'„In,111 nn,,''P n.n11111'111;d'n1.1,nln 11,'„Illn'n Linn'',„I nnlinn,'"nn'll'''Inn'n,00,1'In'„"nn1011''11,',(nr
,, di ,1,1'nnllin Innnillrlinill'n1,',1''1 10,10',','n11 lin'''',1',1,1',11,,In,;n in'nn'n'nn nin'"InIn',VI. ,^',,11,f,',1,Ftli/,t,)1,', 1,',1,11',,,,d1'1,:1,11111111,,,l':1,1CW'll niwm111111111111111,1,1))))
1;11100111111111m/(1"11111,r11,1111,111,'Iillciiiiii'l,,i'':,,'Ii,,:1,1:',)))(),',';',/,1f,
1 W 11:1:111iiiiiiiiiiiiiiiiiiwIliiiiiiiiiiiiiiiiii du .,.'0\1';"''. '1"/101/Iiq'i'''''Illl'll 'i'ffffIl ^' ,',1 ' . '11'''''''l'i'('I'%(4)1''''Ull'''''14(1'Pl'I'llill''I'll'I'11111111'1 11'11111111'1'111111111111
"on,1,1,1,,,,I,Y'll',11,,1101t;',1'1,,11,11,,,ir,1111'41,h,p,I:PI 1 11,1 111'111,hi'1,111'1"1,1,ufithp„,',I111,'10,,I,1411,11111,,,IY,1, 1,0,",„'1111,1,,'1,,,,,h 1,011,111,00'11,,1 II,:Ion"111,1 u,;11',1'11 'il,,,111, I 1
1'fl,11,11,,,1 1, :,,,,,i1j111111 q 1,,,,HHHHINIIIIII11,1,1,1,1,1,1,1,1,1,111111111111111111111111111111111111111111111111111111111111111.1,, ,,4,,,,,, i,(
11„'„"01r,11111 1 1
1 10,11:,1,1,1„1,1,,1,1,'1,1',11111)11,'111! 1"1 1 1111
111 V111111111111,1,10111,1,11111,1 1,b„,1
''':""'".0000000000iivinviiiiiiiiiiiii111111 1 111111111 111,1 1111'1111 1 1
11111111111111111111111111 111111111111111111111111111111 il 111, 11,111i1111111111)11,1111,11,110101111,1,
11111,1,111111 111111,11,11111,1111,11111)1,10 100„, , ,,, „ „ „ „,
11)111111 1,111,11 1111,1,1111 11110 111111111,110,1,11,1 1110,0,11,111,11,,,,,,),11,1„)111111,100111111,1111,111111,11,111,11,011,,,,,11/,,111111,111,1111,111,1,,1111,1101,
1 1 1)10111111111111 11 11111,11111111,1111 1114, 111 ,,00111111111111 1111 W1V1,, 11-1111111111111)111,11,11111,1111111111)111111111,,,,10,11,11,111,1111111111,11,11,1,1„„,,,„,,,,,„0 1111111111111111111111111111111111111111111111,111111111111111111
II 11,1111 ,111),(1))111,11,1111111 illI 11),,,,,,,,,,,,,11,111,11,11,11,1,111,11,11,11,11,11,11,11,11,11,11,11,11,11„1„1„1„1,1,1,1,1,1,1„1„1,11,11,111,1111
11111111111111)011,111111111,11,11,1111,1,111 111111,1111111111111101,1 110 1101'1,11011
)11111 1111011 111 11)111111110,11101111111111110 11 I$1111110111,0 11)111 11111,111 1 11,111111,111111 II 11)11)11111111,111r 1,1111,1111111111111 1 1 1 10 111,111111,1111111 101)1111,)1111111,11,11111111111 1 I 1111)1 ),1 11 I I , 11 1 01111 i
1,1,i1,1,1,11„11111),1
110,11110,1 11111111111111)1111111111111111111111111 1111)111111111111111111111111111111111111111111111111111110111111111111111111111111111111111111111111111111111111111111,01111111111,111111111111111,1111101,1 lull uq,R,,,'1,1 1„,,u,1 l'1'11,,,11,0,,„,11y, 1
;II
,
111,11,11,ilor ,11„„,,,i,„1,1„1111„11, 1
111,11111111,111,1111„1,111'1,11,',1 l'„;1111„„,1,1111111„,1,111,11,111111,,,,,,,,,,1,1,11
0'l'''ll''1'1111,111:001010"0,1100101111111111111111',10 Ill 1 1,11'111111'10''10 0'nn I
'''n n''''1'111(1'1„1,1,101i 0,1110111111n11110!IT n non1101n1Y1°1111,1V911101In'llin'10'11"""1,"01Y1'111,00 0,000110, ''''t,k,:''lln§i'llt1111111'110'11 ''','"')''''n ,,,,,Oneolinne,041' n 11 11°III'P't''''' n In 1(1 lio 11'1'1, 11''''') l'I'l'I'
1 1\ 10
0n11°1111011110'0"111 010' 1 it nnill',010, n1111111111111100
1111,n1110'11 nnI10111111111011111 1 ,,e,„„ :n,11111„10nA0001001 /111M'
IlInnl''I'll n01111,01111'4111'1'1'11
10'10 nn°11'n'n1,n 01101 101°041'1h 0 11110,1"1111001 IIVI:1'10,'1 In i11 I 1
iii 00'1 111110'111"1,, 0 n010111,000 0,1011„1?1111,0,0'ilnInn01 I
1 1'0'111 1'n101110"1„0:11"1111'10111':°1'1:00 1'10 , , n,
0,1
0111, 1
''n'0,10101'01 0,'010,0101111,1001 n''''01°10'0,I0P 1,P1 n1n 0°0',1,11 1,,,IJ1010i.,0,eZnn nl.o.',,ett,l', 0i,n, '1111'ignnn 11110 n e
'111 1' 1111 I ',' 11' I'll'1 ul'd'r'ioill''lee,11,111'11)11?'U::4'11
' 'L'I 111111111 111
hi1W11;:,ille11111111'1''ill 1 l':le'*"11..1
,,'Ill:'1, I uP!')OOttt tl° I 111
l,,,,,,„111:1,11,1„,,1111;,1,;i:5;,,:1;v11,,I,,,,,10„1;,1„1„,,,„1„,„11,?„:
lop
,
„„1000,11,,, ,,,
'
, ,1
0[11,110000(010,11,11,11,1,
1,1.111,11,111 0111 11,
,1,111',I';',111,11111,1 1,1
'',,'"11':,',','111:111h,'',',11',111,I1'11,111'ql,$11,'1,11:1111,\1:,11,11I:1,j111,1'11,1b,,I,P111,,,!,\11,„111111,,7;,11,1114,1„:!1:111d:11111P 1
:1'1,1,',111,111:11VI'lr,b1q.
fl111:1,11"1'11'1,11111'P':711',,',I,1111,11'1,,,, ,1'11„,111"11,1111h,,'1'11111111
1 111111till'L,IdIP 01,,,Ipy11101,11111W 111114,1111,111,1',1,,11111,11,1d1111,',',11,,,,,„11111111,',1';',1,1?:11,1,'11,11,1,1°,1,„,,,1,11,h1,11111,o,11111„:II,1 0
111101,h1„01(1,101,„„Inlh„,111:„,,0„,,h011,1„,„„hhosults,#;taihioe hoi:Nousoh,w.ippvi!oll,,,,. „ 1„,,,,,,,D,,,,11„„hoo hn„,„,,,„, . .
, ,,,„1„„„„„1,,h Ili 0,,,„,,,,,,,,,„„,,„,,,,„„0 111,,,ho,„0„,,11,,„:„,,,,,,,o„0„,„,
caLfornia
1,1,1:10010,1,,,,,„,,, ,,,I,,,:„„*„1„6,6106,,i,,,irlio,oltd,„0;114k,y(1111011,1foiepi,,dati,o4fri,,,1, 1„,,;11,17,,!1„,,,,i' i.
y,,r,!,,,,;,,11,,,;,;,1,1,11,1,1,u,,,l,„„,,,„14,1,1,1;,,,IP:,,,;,;,n11;,,I,11',1,,, '''''t eat h at„w ,laness
wi,14 01„,,„,„1,,,,,I,,,„111,„„6„„,11,1„,„,„,„,,,,,,,111
,,),1.4,0
l',',111,,,,,111,1111,1 1111;07,1, 11 p„,
1,11,11,41,,f ,1,111,,5,1,!•,',,'"1,Y,11;U,' 1,V11!yT,, ''''‘
11,1,,L,,,„, ,,
1 1,,1„„olvi,,, ,„, , 1,,,11'111,,,,1,1,1, '11l11,',11,1,
5f 51 r.a 5,1 II;,"111'1,1,111,I1,PIIIII1,11,,,,,i1„,,,
How to Access
„,„1„,„,,1,11„hhohn,1„,„11,11hh,h1,1,h,h11,01,11?:„Iih,hh,,11411,11,111,11h11
. „0
1„1,0„„lihno„(1111,hhh11,1,11,ho, ,,,,,„101,„1111,1,1,„„0„ 1 ,:h„,„„„„,„,„,,111„hhh, hi 1„ „1„ l'" ."'i," Rout 1 hi he Nte 1 [cal
111'1"1100P00e$1'6'11:1,11041!1111'01/1",ii'l'I'll'IM,Piel!Pi!il!h !,111,1,11111,„1 11! , ,1,1 i., ,,,fi'I ill ,,oir
,
l',111111 111';'111,1'1,II"1,11111,1:11n,1,,1„,,Ill',n'1,',1110,111,11,I111,10 II'ip,d1'''1' 1"11I11111,10' 111):',1111',11,111,1''111,,III'Iln'',I'114 110' 11I, ,','IYII111'
1 II :1'11111,1,111'1',
,,e,Ale,„„1,A,A, ,,,,,„(„„, i ,, 1 ,,, ,r,04,1,1„1,111,1„1,011,11,1, ,A
atip9011111u',11,0,r,v„111,1'1,w1,1541q,!Ili,qiiglAmo,,,,U'llui'll,1„0,,,111,1011,1,1,,,111,, LogistiCare Solutiolls LEX, 'Transportation
„„„1„h„,„„, 11,111110,,„oh hh„,„1„,„1,1,011,01,,,0 „;,,h„,,„
h 0 0,n00„ „,„„11„„i„
ho1„111„ ,, 11stiLar
,,,,,,h,,,,,11,11h,,,,„„„„000111,„11„„n,,,,,,,,,10,1,„,„„,,,0„„1„,0,1,1,,,,„1„,,,,11„,„,„„,dm
www..LogistiCare.com
111H1,1,1,11 111161„,1,',u10 110iii,ii,in,',,,r,,,,',,u4,1;1, 01d,,illyai Huullh,,,,ucall,11,1 1111,A 1,u,11 ',00 ,,,,„,,u ',u,
,11'11'1.1'Ul'''',',11111,q11,1 11,u,110,1„11,1,111,,111111,,,I,1 1 1
U,1,111„„,1"1111,,u,1,1,111o,,','Ill'1,1,,,,,111,,,,,,,111',1'1111111
1,'11111,101 ,'Olilili,,,,,, ,,,,I,Inh,,11,n,,,,,,,,,,,,I,11, 11111, 101,1,u11 q.201'"/by LootiCare
111,11,!11;;;I';',„,1„111„„11,plb„10to 08$10 01,111'n ,111:01" 'j'A oo,'"11111,„I,„I lidl
,1,11,
1„1111,„,1111,1!,,,11:,,:11111„,?1,11„„Ilholli ,,d1,1„„1:,n101
AIIII Rignts Reserkned,
'111111,',111,11,1,11,1''','',,,',,l'i1d1!;11,1111111'',,1,11:111,11',1111:111:111,1'1',1111111:11111111,11,11,11,1111 ''11'11,1,'11111111'1'1'11,1111'111;111'',0111,11,11',!111',1,(1,1,111'11,11'1111,11,111,1111:11,1,1,11,,11:1,1,11,,""111:1.11,1„,11',1111,1,1',11,1'111'1,11,111111'11,1,1111,1111,11111,,11,1111,,:,,110'I111111;11111,11111111111,111'11111/11111U11,1',1,1„1,"1:11,,,, controY code
11111,,,,,,,,,,1,,,,j,411111111,1.„111,'„,,,1111,01,1„'"111,1111,,,,11,1111'.,,,11„III 11111111111"'"''1'''''''"111111'111,1111111110141''00..111,,,,,11111111L,011,0 01,1,111.11',,,o,„„1,11,0'1110::,1 11,1„,,1,11,111,11,,,,,,1111,u 01,11,1,1„,11,111101,11,',„11,,,0,'
11011'0,11,1111101101,,,,
11.,1111,0110.11,11110111,,,,,,
,1,110,100,1,'
11
I Ii ,,,,,
„10,1.1,,1,0,
,„',01 1,01,,,d,,,,,,,,,,,,„,,,„,,11„,,u,,,,,,1,„,,,,,,,,„„
11111',1 u '11' '1110‘11,11, ,
'111,011,1010
u,',
,,1 '111,11111,00,01',,,,
,I,I1"
,,,,,,1111,11,11',,,11111111 11.10' 1
11'1,1111111'11111,11°,111,11',11,,,,u10,11,0 11,,1:1,111 1' 111
,. 1,11'11''10111,11'11',"1,1,111,1,11,111',11111'hi''11,,,,4111,1,..1,1,1111,111,11,1,11,1,11,11,11,1,1111111,00100011000000000111111111111111,111111111100000001100110111101 0 0 1 1
"1,,,,,,,,,,,,,,,,,,,,,,,,,,,,11111111,111,1111111,11111111111111,i1'1,11111:1,111141'1,,,,1,:,,,1,11,,,111,,,,,,111,111,11'11111111,11,'111,1,,,11"01,111'11'111'',111,1111,„,,,,,,,,,, 0„,,
1'1,1,11,11,,""'"'",'"nr11011,'„'„1,,11,11,',,,,11.11111 nil,',111111,0011,11,1111,11,11111,1111,,u,'"'
1'1'1,11111,1,11101""'111,11,'';1'111,1'11 I 111
1.1111'1 11,11..0,11111,„„1,,,,,„„:1,111'.111,111.1",111,",,,11
11'11',001111,'",11,1111111111111,111111'"'00000000,,,,,,,,,,,,,,11111111111111111111111,1111111,,,,,,,,,,,,,,,,,,,,, , ,„
,1,,,„,101,,,,..,00000
',111 1 , ?ijil 1u
n nd (,)1 ,,('l (,,C 1)1 11 n)JJ n.1 f 1 lin A i)n f On:MI,,Inn'nu In, "unn9,1111111111Innunnunnunnunnunn'n111.1.111,
l'n','11'11.onl,nnin,1„,111,,,,n,'11'11111,16„II,n,1111n,,unn
1, 1' ,,01111,0J11 1'Inn Illnn,0,0,1,,1,1,1',14,,'Illn 1 Innillnp,1111'1,11'„1,n,noonY'11,1'din Ill o,'',1;1'n,1,,,nn,n1 111111n1linn,',onn nnin'611,111,,',11,11,111'1,'n:1,n1111 i1{ I I A'A' '''''''°''' f'' .' , ,,I'l6(,,„/(Iiif n#',//d11".1)1I,,
'91111110 i n 0,,11111„1
II' ''Y 111,11111,r',I,00,11111111101001,111„,,,,,,,,Npin, I
10,11011111111,1'1'1111110,41110 on,I
liV,1?1111„1, n 11 „
0'n'01,'I l'0 11'111,1,00',l'1111:0'01000111'111,1,1,11'1 oll'i,11111:1,00,11,111 41,,,,11,,, Ili,.'i,'U),113'''1')/1),V)''Il,11 ji,,,1111111111111011,HI",
'111' '11111''111 1,11,1,1 1:100 ,1 111111P1,1,,,,110,
111 0'1111,,,1,1111,1111111,00',11 1110,1111,111°111,,
,111111 0111,1,11,1',0111011,001,1,11111r 1' 11
,i'1'1110(::1'11111' 11111 1 '
11„,'1\In„,111 ,11,1,1,111,1,,,,,I,,Wi\,Ipiii 1 hl 111,0 1,0,11000 ',,,,1,,001010,,',III 1I1
10 0,„„„„h 11,11,7,11,01111111,.111110,„t f 0 in 001,ruu.00r00,000r0000R00o 000000000000000
000000
0.out00•001 0000„ T r a n s port a ti o n Fre . entlly Asked Clues 0 is
,u . 111111111111111111111111111111
IIIIIId 0000mo owl° 001 p000000000po
Depending on your location and condition, 111114:11Ii"in:44 ,15 4 G' 0 u 161111r1"11 What If My Ajapointment Is Cancelled or
types of transportation scheduled can be: ilhol000010000100000000000000000000000:000100000010100:0000000000000000 H h led?
0000000000000000000000000000000000100010000000000000000000000000000000000000000000000000000000000000000000000000000011000000 nesc-edu
000 0000000000000000000000000000000000000000000000000000000000000000000000:::0000000000000000000000000000000000000000000000000:00000000000000000000000 Please call' immediately and let LogistiCare
0 Car,van,taxi '' 00! ni i' iiiio'r+hri44,100iioii:00Stliili#0000IhiIliiiNirllSIl0000i0""
0 Wheelchair vehicle 111111 iiiiiiii 1101. Ilts.10,00,Agiroxii0000110Rill 10111110000h0110400001110010:110lor know the change in your schedule, ideally at
000000000:000000000:0,,,, 1111111111111111000000i01101iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiopiiiiiiiiiiiiiiiiiiiii i illoolooloo:
1100111I100000000000000000000000000000000000001 I
Mass transit east one hour before your scheduled pick up
00000 " '''" 010 011111111111111110000000000000000000000000000
1 1000000 i0 00000000;00 1111111111111111111111111111011111111111111111100000 time. Your courtesy dlows us to betiter serve
If you have a medical emergency,please call WIN c 11301Ialtglli08110$
',1501,1,00,iirg opto,,,ortationo,„14,401:::: other members.
911 right away. 'illrf0101 iiiiatinit i°111111S0041111,14I,0010,110111,iiii tplillIWIii0illiliiiiii
0 011illiiii,10°VIIIIIIIIIIIII,IiIlIIIIIIIIIi Is there a mileage IImIt?
Cost: There is no additional cost for this 000.0•• , , 10111111111110111111110111111119III1111110100111110Milil
s 1 ,rsi ir,IrilIllilli nopall111 00 01 111 17 Yes, each one trip cannot exceed 200
ervice.
'0010 1 r0 11111000000 0 000 .. Any transport that xc
es
H 1 1 0 1 101011 Ivo p hvo ilojel 0 0 0 0 II 1111111111,Ip 0000 ,111111111 iobiooloioilIl1010100,10?0001iuginii,,,0iiiiiiiiiiii mii . eeeds 200 miles
II 0 0,100t mi0rryn00i0ii0i00,00,00,0i„iiiiiiiiiiiiimiiiiiiiiiiiiiiiiiiqpl
one way will require a prior authorization
Hours of Operation: Reservations need to 0011000Illillillilloillisip,i0011 1 00 i
.000001111111111111,1 iiii010000000000000000100:0000000.0,...iilissisi iii
be made Fillonday-Friday,from 800 a.m.to III$iilIllIlrIIIIIII0IIIIIIIIIIIIIIIIIIIIIIIIIM""""'
iill000000ligiviliiriiiiiisiiiiia00,000,00000,00,000,0000,00,00,001000hisisiriasiiiiiiiiiiiiiiiiillilliiifrom California Health and Wellness,
600 p.m. PST. Illoaalll,*,406Eiia8000 ,Illiii,IlIllIlliiillIlliIlliIlliii
i4Illigilliiiiiiiiiilliflliiiii0i004000011006001i0F00000lifii,1'11111'1'0111,4,hoi,pgil i; 1 S there a trip limit?
. 1001101 II 00000000000010000
,0$10000000R0111010110110000,e0ggg0070,00000041001000,4000000,00010000R00000 100,ill00,0110000000100000i00000
Nik/hen to Call: P1 as call at least 5 days in iiiiquidi 0000titiiiqi140Mbilkilf0 iiillefiyal,, filipit iiiiiiiaffli;ljt
iipii100IIIIIiiiciimiiiiiiiiiiiiiiiiii
i iiiiiiiii00„,iii„,100000 No,there are no annual trip limits.
advance for Mass Transit and 3 days in '01,IiiillitalitiiiiiiiiiMporaiiiiii0500)00$50:040000iiiiiiii ;4I0:1000i0iiphiiiiir!
advance for aillother transports but no more iiIilolilliiiilipl$iiiiMiiifIllifilailiiirigilitg101iiiii,ifORIIIIIIIIII IIIIIIIIII1 What If I Have a co m p la i nt?
than 30 days before your appointment to (Ol00000Mg0000000000000lllgIR::::rll R 00
d R ""sd0'00110k001,0„,0100,h,,,„,leo 1 d,,,,„„l„1,,,,,,,,,,R,,,,, 000,0000,00.0000 000,000 0 sop doode:0000 0 0:Nil".
00000101,,0010000000„„,,,00.000,000000000000000000110100000100„„„1,,00,001110000000100001000000010011000:0 Please contact California Health & Wellness
,I q111114101111111111111111111000000000010001100100000110011101100001 Iv° 000000 r.111191111000001111111 lonollt
,dill'ill1511'N'F,u1NAI[,1,,,,,, 111000000 111111101011111 110101,:liliiliill1111111111111111111111
make a reservation, 11 owl
i0000oil'ill'i10ifiiii,000,000oiiiiiiiiiooiiiLlglfllillIll,liiiflifilIllIlIlIlIlliiIlliliIIIIIIIIIIIIIIIIIlliiiilIio00000ioiliioiiiiiiiiiil! 1
iiiiiiiiiiii00001111
customer service department at the number
IIIIIIIII0IIIIIIIIIIIIIIIIIIIIIIIIiiiiiiiiiii iiiir0Sraiiiiiiigi
Locations: Transuortatic,n can be to a0-0. oelyil000•001,0„,,,„0,0000mielltiorg,,,,,,,„0000,10:000000=0:000000011:000 000 1111111 000110111:1010001000k0001
1 111111111111 on the back of your member ID card.
facility that offers health care services 1100,01001000, II 10""rd0v " , fill 000,000,0000,0„„,,,,,,,,:r0:000000ll00
PI 001 110000#011111°000F,011101,FEIVIPP!!0!01610606:10*#10'00 Wh t If Id" U
covered under California Health&VVellness 0000100101wHog g 0 0.00 0000p001.,,„,
'°°'" 1111111 An"114!Ill!r10110r!000010,01,
al: a 1 Urn nsure of the Time of My
I
°' 1111000h0V110
Ol0 lool ;it 101 ill l000010iliillilll 11:0000gldtqdl°00000000i0000000trolorrola00000000ll
00 0,0400:000
,Itooly,,,,,,,,,,,,,,,,,,01,10,,,i10,1,110,0qho 11041„„,,,,,,,,itg,11,1,11,040,11,1p,,],111!„, ,,,,,,,,01,00p,,,,11,11,11„1,111,111,11,11,111,111,1111,1,11,11111
,,,,,i 1,0,100, Return Trip?
10011MOlell000 11 :1 R , ,000R RR Rd 00"0,00000400olood,1101,1100000:1001,a,„olool000loo If you are not sure when you will be finished
00,000i0,10„010010,10'00,000,000000000001100000,00,00,i„,0000,„011011;10,00,000,i,00,1000.0' 1'01'line,iiiiiiiii 111010
1 i Illi' l''ii100000090100isssa$110101,igulliiiiiiitioilloil 000 Imo 01000011opup4,10,„„,,,,,00,„„10010,00,0000 .
with your appointment, please call the
liii10,1i 0i 1,OlititiftiimoOriiiiiiii0000000000000000000100000000000000000000000:00000000000:0000000000000,00000isigi0000,04000000000siiiiiiiii
iddifiliiiiIiNtillimilli110:101001111111011igi,iaiiiillillilillifilloilloll$1111111111000911illliiiiillilliiiiii111111 i 1
0IIIIIIIIIIIIII Transportation 1-lelp Line at 1-877-658-0305
IIiiiiiiii 11:1 0-arliOl'ILInPo(kOl'O'llI11,0O.Oolooloto9,111010)0011111Ohl,00lhfdrttiattorololoOl000l hllooR0000,
0,0,00d0a)iallablelliOheOilriilciriOlandRidegiiivoloi/cid0 0101,d0„"0;110:'.0", 1,00104100bl IlliTilliripair011.ifillipol,000000404011800000iliLl0d0,01i311010,10000r0eiheifiRRIhrli to nil k r: 0 - following :
a o a langiments your
100000110,„oily„00,0 1 1 111,0100,10,'''11,,,, iiiliiii000000i Is 0.10'00000101,,,„00,,,0'i „,101,00,Ai,ii0iiiiiiiiiiiiiiiiii, 110111000:0101001111111 ,1 0L., ,011,
'1§i:l000010,0000,0000 i iii- 0'1' 01.000.100,00',0 III',iiill,ii VO 6 1,
111111111111,11, ,i,a,Ofiqy,a,,,,,,,,,p
VI ItlilWIIPkd'iliOiONAII10111;illiktfii,,,It'Oliii,,,, appointment,For nearingimpaired r-nembers
010 ",010000p;ooiriloot,iibloa!tflroaii.,11,,,im 1„,;;1,01,1 0 4 1„„,1101,1,1111„1,„„ liii qiiiiiy1101,14mu,,IiipillyottRi,io IIII 111,,,Einnull E '1)
0111E1 mlifIll' ' a
ill111411111V1111hfifil011110i0000141,0A 1111#114 04,p,3041111
41 INI pleasecall 1 866 288 3133 PI hthe
- - - . ease aye
1 1, ',:1111111111111111 HI',u111 I 111111
I 11111, 11 liVipl NI ri1,111 dOleJ-1,11,a„,,,m010,40,,;;;;,1'1 A 10,1,16,pelk,140y, 1111„111 ,e,, 1111$i,,,o,11
11,,1,1!Ii!!k,1,,1111111,11 010,1,1111' 0
1..,11,001110.1rOvialpia!pedgyooh 1111,11111„11?111111 il illy'v h11,„1,,sor(ey'll 1^.tt,,,wrinco ,!ilifix 11011f ,111L'Ivo'^"Oirilijiii address w he re you need to he pcked up
111111111 ',„,11,111:1H1l'APIOCinOt00,161:0*I'''' 10141,/tirOle'?1111111"1110'11111'Pe' '11A111111111511'111111111'1'1111"' 11 I i 44'10,11,111,1 000log000godoog0000loopoo °or
1 1 lop,,ur , ,, 0 11111o1111111110111oillviipliollorrilt,l,,0A$opotif,0,1,41,00 a ailable Trans tiwill ii
0 v 1 . ranspor a ion arrive within
I0001100,,,,iiiiiiii,,i0,000,0„,0,00,,nit, 100,0,,101,0„011,0010,000'„1,010,000,00„ 111,,0,00,11
,V0,4000':osoiliiiiiilifllhlli66'FilliemitlillIlffli,00,000ilif'i100;00IflIllif'ilIl0'lllifilii,lfPhqR6ItllIllil
iii0,0070,0400,0,19157Ypipq00) 11,9p004,J0111110;,o,,,,p,,,m,01,1,10,q0,010,00,111ii,i105; 1111,0,0000010,01,0,11:,,no„oOOoll loqiililjodoolool0000000ol0000gool00000log000totoiloOlP00000llool1010000loollIoolooloo tollog011r0tooloolloiloofjiotoo01400 all hour,
i0L4i,leilleI00001Allct?oilli411400019004IIIi„iir;i1p!,,',3111,1oi,I.,„,,,11,'Ilri
11111111,1,11,11,1,1,1L,111,:101,,,,,'Ir1,10,111111?,11,11,1,,, ,1 do,111,11111,1u,0:,111111!1,11111„11J;;111,1„„:11„1„11111„0011,,,„1111111,1111h1010„;:11110n,i11:In,111,1111111110111111;b:,1,:11. oologi!„1,,;,,,,e,,,4101,11;!fi irililltill,kikottiowog il, 1 iiii,Itilmilil,N011111,111,111, Who Can Call to Arrange your
l'RRR,010'1,.10:01,00Rdll
RldIRR,R0R0d,„1000dR100„dR01,,,,,doR 0Rd 1041,000R„11,110,R1d,00000,010,1,rdl,00 R'd ddloddR,100,„,,R0,00000 10
1 1 1 '''0,R00000100:00,001,000'4,04000„„0,Rd100000000, 0,0,00000000,112000000000.10,10,1,000,1100, ,0
I 11" l HO 0100000000000l0000000000000011hOoolo 1101 T 0 00, °010000010010111111000 0100 0000000001001000 111 V° Ira nsP°rtatlian?
dd 1 ,dRddi dr' R dldR,11 0 R'R0000„0,,d'0,0R0 0100:10 ddd '111RR,0dR0R0 R 0,000',0,1,,d0,0 d",d00,10,0100000d0„,10,00R,100oR'd,0RRRRR000,1R.',R" R,„,„,.00,000,,Rig:0440410110000,10100111,0001111 "
000000010000040000000000000000,00,001,000000000000000000
R. IR 1000,10an000000000000000100hu,
0,1„,,,,1,1*,!tegyilliv„,,„11,riferiorlated,1,1„,
.otilitifOlogie;mosoolowaltoofOgooloogoo You, a Relative and a C '
1Caregiver
i0,10.1r IIIIIIIIII fill'114,,,,otijkisguggglogfligill'ulRigk,iiiiiiii'm meigeliiiii;
...,,,„10fidli,,,..,,,„„„„„„„„„„„00000000000,000000000000000000001111111111,11111111111111111111111111111111111111,1111111111111111111111111111111118111111111111111111111111100100000000000111111111111111111111111111111
1,000p,,„,,,,,Inoinollionadon000nloonhomonolooloolooloonnhooloolooloolooloolooloolooloohooloolooloolooloolooloh0000000000000ouholoomoo00000000oon000n000nolovoloolooloolon
l0111[11111111111100 I I111110111 IIIIII IIIIIIIIIIMOV10111101001011111111111111111111111101111111111111111111110011111111111111,111111111111111111111111111111111111111111111j11,1111111111,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,1,11111111111111,1111111111111111,111111111111,1,1u1,1,1,10111111111111111122t211111111111111111,1;
11111111111111 1
i cite?
o oop000 oompoomol 1111111 11,1,olo
0 0 0o o moo 10 lii0
Illlli111111‘,15111fOliiik000mooloolooloolooloolool000
napoolo 1
i cancelan Ia n m
a cam
a
11110 1,,,loolou millpgri°loom 10000m00000.11ool.,001
o. 111,01hooloo,111111111 olly 1
iii .,„,,, pasa s
No110,1!
'': diatarri, su
ente e I'dealmente
cita,i
ovoo lookili11.1.11J1.1.1i)1 11To.1,1110111 000,o,o,00000000000000000000000000011111000!!!!!! lanie Idme oambio en de la ia
de rutin•o
IIIIIIIIIIIIIII'''''''''''''''''........gIIIIIIIIIiihIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIH a,
111111111111111111111111111111111111 lood 1111 Foil moo°III 1000011100001,01000,000°°°°!!1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII L .
1 o 1111 000ll00000011010110111111011011111111.1111 11/11.,rid
1 1,1:1101411c"Hilli11111111111000000000000000000:0000001.. del
tiCare
togis no
',Ina bora
hora antes.1 Su cortesl
rtell ll 1......................,,,,ivol,,, ,,,,'',' (,.1.
Tra nsp
l''l'1'"'I'l'''j'''I'llIlliIlllli'llhllhIIIIIIIIIIIIIII'll'''l'idoou00000009!1111111111!lvuo 00000000
gerlo(a./' ,,,,,,,iembros.
al me/mada para
et ros-i'
,io v de su iiiiiiiiiiiiiNiNt„„„„„„„,„1„0111111111110011111.
oloolioien,000.0000iiiiiillhooriailiti,00,0000000000000'0000000000000000000000000v,0„1111111.111111.1.ritirt100000100 nrogra
11°°°11V°°111'111111111111111111L1Iiiiiliaili00000000000000002k00000000000000InI°1111eill11111111001,1101111111IiirallgIleragiliTiii,14101111111 ecorejo r a
P re gu nta s F re c ue nte
do de
ite servir m
no perm 7
De
Pdelrlcdidiennlostiposrde
11111L111111111111111He'41111111'16111111"Iff'l I 111111111 "11111111:111"1"1":":":":":":":":":"""illiilllilllIllil1111111111:111111111111111111111111111;;II1111111I11,11,11,11,11
11111111111111 11 1111111 1, 11; 11111111111111111111111111,1"11.=
iirnite de millasi ion
no puede
i it pueden se . taxi
scoorc ar su truabl-scpaccrten que puede
1111 '' lunnialiiiiila IN.
111111111111111111111111111111111101111NN.N.N.N.N
Ildillf1(1111,1111II0000000000000000110000000100000000,000
11. 0
11,1110000 ,0110,00,00000000,000,1000
.........00,000000000000000000000000100,01
"recc
, 1 Hay lin ria dlsncir •
elooloo, Ii0000000000110,00,0000000 „ , en ca.__ Todo trap , te en
00,00iiii0NI ,I.,,, 10001100°°11111111°I0010001111I0001110101111
es 1 ta
Si, el viaje200 moles.
, ovilr camiondeetar,ue
das
I ' IIIIIIIIIIIIIIIIIrlill7,11 vi,-Ii.„,1,4%1
00 millas, Hect,_
Auhiia
11 i ololilillIIIIIIIIIIII111011101oll011101ii1011111,11,11,11,11.vini,,,,
exceder,de
las 2
,, exceda
California He<al ri 6rs,
fcmu 1 a P a r a,s 1 li Ica°
110011111111111101010011
IIIIIIIIIIIIIIIIIIII;IltoolI1110101I )1t;ptilii01.01111 due el yiaarj-torizacion de -
TVreadspolite Pub ,,,„„e•dica, lame al
4010011,0111i101111110,111gglilyitirliii1011041011111 IIIIIIILI {111111111111111111111111111110011111111111 dna pres
n_ _mergencia' '-
10 la H wei 1 n es .
Si tiene a u
1L:idiatamente,
olrol i 000000mum.....Li0000liOoo,Il ,111111,1_1,111,,,,,k11!„11 11 111,000hoolhoo,0-1000:::::
111101001)10010000000000000001,11,01,,,,,,o,:iivii,„,rr
de via j ?
i 'les.
riir 71 1.1,1,1„1„11,0000,,111111111111,111111111141,211111111,1„01,1,„v
para viaies•
911 Inme
vicioi
Hay un iirrtite
este ser ill' Ili' 111!rollioltgloo 11111111111111.1pIlligliwoviiiiirtgal111111,111,11"1111,1111.1.11111„0,111 4hay
brara Prr
limite anual
le co
1,011,1111401,100,0111;11IIIII
01111111°I111111111111111111111111111 II Ilo
1000111111, 11111111111
. ""iIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII111IIIIIIIIII00,00,Iii No, no
Costa: No se
reservaciones ,11'01,, ,,,,,,,,,*,,,,,,,!!!,,
,„ ,01,,,,L,4,111,11,10Qr,i,!Ilt''':,;,,,,,,i',,i111::,::,,,,;i1,1,:,;',,,„iliii,,,,,(1,,,,,,!ligrooL °I ,,,„e dueia?
eracionesi Laess
Dun a viernes, de
100.00. • hago si teng0‘i.i"
de servicios al bimieentroe
Horano d •p
iir0i11111010111110111.0100iliii01010011101101r11010111'":1c0i0;0011'001i11111°11111i:n1.1'!i",1°';111111r,'111v1,01,1111011t1,410101R1110100:00210010040yyytil00000000000000! UC
til 14411
/clepartamento
& Wellness al num de
nen q
-etl• hacer de •010ro Estandar del 0111 010 it11000000101010110001100101111iiii011040111011Volliiiittliofpp,9110tril4tolttl11000 tiame a ..a Health
00 PM I
800e AMAM a 6:
1 0,,, III02114ran *IIIIIIV414 '
tres de su ta iota
illOrlialiMiffigrill5g IV'
t/forni
IIIIIIII°o1iooiio,IIIIIII*1,IIIIIIIIIIIIIIIIlliiiii de ca • la parte de a
Pacifico,
u reservaciOn ll.
ropilli)fl$41:101,i,,,y10,141001,.4IIII4!II111IIIIIIIIIIIIIIIIIIIIIIIIIII00,,Illriiiiipooliaa001Noloop.000100010000.1.0iiiii
1111°01111IIIIII due esta en,
i•embro.
11011)'1'1i, 11111iIIPTViii;,1,,4111',11'i,,00;ipo!iito'1
H del m
h a rer nu tra nsporte Illli1001illIIIIIIIiiI,NN il 111 1 fIl iiI00100111111110010.111001001VILIrlei,Ia1N,
identificacio
a a, ..a or
, do hamar:„Pa•rr:s
0101011111.11,401100.01110IiIIIIIIIIIiii,,i,ii#140(c,,,ripo,10i, ,410
r de11
segu H
cLian
5 d antes parra_s tipos de 0111hq11;11y1111I111IIIIIIII Fool
0 p.....,„i II, 1,11,11,11010,I, 0, g a
titS/111$14111111PP'171117''1111''10#01#1913iTS1!
si no esrteasyo?
Hanle al m„,,enduisas antes,•pdaera3e*tdras antes de „,1111L,10,1100111,11
a ue Pasa
'01 #11111111.6 ' 110Ii '''XilltlIritid*,Ittto,.,Ael).1100I0II1I211000000111910,,,...lililii d. .yiaile de reg
re
n a ra. su
pOblico y .J
era no mas
010Iliwilfl
119°k11‘11 111111''Illiir'116111'1ii111117'111111 °111 111iiiiiiiii111111111111111111111111111111101""""1 de mi
andel term. a de
a ospbrte,P
nallIIIIIL0,11111
ro(a) de cu iTa a la line _,,,,,,.
1.1111NalliII11II,T,,, . " l
00000.0""lookilakeiroliaiIIII:001,111:1,111111 ,„001011111100II SiliooPil.IN
10111,11.00.ii,p0000eiri,„0 ,11„111ii10,011,0'14„visi.* 'all , no esta segu des de su,c1_877-658-10'6u
01 r1 lilmanglIIIIIIrdiaaiiil ,
IlIIlool
! lame desp
su
cita.
Hal ci uler IIIIIIII..i IIIIiIikaztil r III An
MI OilyplitLi,,,,11 1
orte at 1 es miembros
te puede ser a daTteric,,a,,,, i.
tltl! IIIIIII001100I,IIIIIIIIIIIIIII 1111111111111111111111111111111111111 II
looroti111001,o1IIIIIIIIIIiii,0000, cite,
ara transp
ILio" Illt‘jIll, 1,1011111114*1:10PEIIIlit111111111111111110a111111Illoola111100000I
11111111111111111111111111111111111111111111111110001100000000010000000IIii.
lolliili111011:lirtlIIill avuda pa cogida- --., garden al
si El transpor
rvicios de
aith 8t IIIIIIIIIIIIIII'liIiaitir..
coordinar la P
r... e a ..,,ien, ,_ is
Logare i
of rezca se
California He
111111n6w1IIIIIII11111111111111111111111111111111111111111111111111111111111111111111000,110111 ,0046,00r,J .r 01111,1,1"111,,,,,11
1 para ..
dIsPddldlu
lugar clue diertos qdr -
?,'tg'l'll 01g11111111'1111111111111111100 0,14 It Ilrr Y11111k "iilli
ivilloolloilloolo0 n.
q problemasnd a uo i,,..
100 ue tienen,133, m g, no que recoger, El
"dica cu
me
iii1111110111111q1
'k 1f111111 1'1'000 01001it 11111* 11111Rg11000 1114
00 0,000000„0,001010,
i00001t.ilLitlioS,e101001101.11101111 1
,, ii•.1r00101011 1-866-288--' ue se le tle de ura hera,
tylin ,i11,11,1111.N.I.111.IIIIIIiim'*Flip!'PIO.leilfr, 15'°IiilifOolc014.11.,Nillio,,Nio . ciao en la q , menos I
well nessi 1 1 0.111,11"ll„,41,11.,,11"."1"1"1,,,IIIII rillIE '''Illi,IIIIIIIIIII,'I1110111114i0IIIIIII,'„goopetillEli
en
ig 1 , 10L4,11'.V.1.10"ilr410114 °,1011i11!":11§',1 dIreolcIsp0
11 III 1111111.1 1111,1 III'I 11111,11111111 it*;111,110P10111„11,i1111,,,T11111111111 Itliiiiiiili'll " t11110#10.(9,01,01,111 ilillii0111111011 1,6114011016111:tv'u* 6 1 rte II egara
1 1 .10,01,11.Hi.al,- 1.1,1 1,,,,,4,h„„rospayla411"Aiiir,iptilailiiI„, „.„ I10000i100
II, „,, ,rmliRlIfi,000111 tra
bordinar su
0 IIIIIIIIE,'10,ill.i.ol'Illfi'IN*I9nialwhillilliill1111111101llilliiimilf10udaaTtmiligriiIiiniilill11010 •-o plied
i.,"" ,„110,1d1 n.illiiigall'IlinLtpralaCII irlIIIIII; 1111111„1,..11, 111111111„1011N.00, IpIallIII,igi ,'„IrarilipiraI001011000012014par:1*,, al la iii
mar para c
e IIa
011101,I1ouriiirri,12.14,1110qx*.!.''.11,1„„1„.111111,1":11"111,11.1„,i" Iolii,„,1110",,lbip:Ili IlloaaiIIIIilcillgill1114,11,0,ipe,,,, * 1
ra\aska'01511° "tolh.,v ' Ili LQle
u te?
i'dar al
11,1111t61!li g„°1111111'11°1111117 ''1111111111111111111 I
1,11!;10111 11111.4,1 111111r,,11(50,11010111111.917";1•11,11,111111.1„i1111 0,10k1P,000117i0000,104,110,100 01111 iiR2,,I,'1,1i011111IIill l""I ll
.1"f„I',IltiI*.rili 'll110,11,Iaail IiIIIII,IIII101,III011100b1100,1111i
11111,11110 1111111111111 transpor ,
Uste', ud
Y a cu
e ..
ini„1.11,1„ ,,,,,,"10.ill 1,161,1dolder1;,1P1111,,P71.71111111 0 I Ill"1
1011 111101111 I'll:1001 11 1,11111 10 1111 11,0111,filliorl,,,11,h,,
11,110ri"("'111'11141i1111111111111111111l000moolood0000thm,11,1 LI''1'0'11,1,,i,f,,, , do p a rf e nte 0 Puled a
101,1111„111111.,„,,,IIIIrde'lri, 111 1.11,141a11111 III 11, 11111.111,11111,1,2,11,1111111 1,,,,r0„,„.191?1 a li 0 a la aaalairalL aala aalliiiir la 111 1 000a 1 Ila I III Na Ilaaaaa,lavalla101110101 al loge,a141 El,nallallala
a 01 Itti1111,'1 aliakb a Litli
11,1 1 lomnpintniolikilliollool,01,1111, , ,,,,
111111111111.11111111111,111111410,1611,10,d1111110111C4fr7;411,ra5klii191111111111.Pirillii10,1'''1111,11,1111111111111111,1111111111,111111111:101111111111111 11 lill 1 Ihilliliiii2 f,6,4,i1,100111,,,,[fia,„luit nun 11000,r,og1111 1 Ut.......,:cte 1111111i, m!ern
bro
101011 F1 l'010#11110416.11,111111,riloilliiraligelliii!li Pilni1111410,11iii l'Ill'il! 41
11)121""1111'101!,00h
I 41111111111114N1dill.' el 11111111111111161111111111111111111111111111111"Illallli llill'I'lllitill'ill41 111111111111'1111111111111111111'11'''"Ill'111111111111111111111111111111'11111111111111111111111111 111' 0111111111IIIII'0,a0#4507i'mq411011"11111111livig4I'llii110:--1:111111i1111111111Voloollooloillop0000000000010001111
11111111111111111'Ill ed i °I Illill I'"4 4111 illi'll'F 1 1 11111111111 li 1 11111111)11"1111'11111"1?1111111111 11111111111111111111111 111111114111'lirlitolitlhalltil'ill,141„vl'Pl' l! 1::oiliIll'111?1?111?1?ltili?l?i?l?i?l?i?l?i?lliyiy0000000l000000000000000000000000000000000000000000000000000yt 1
1111'111 1111111111 r111)°11111.1Y1111°11'111111111 141irl'Illli'°1°°gri9IllliC11 1111111111111111111111111111111111111111111111111
ovam°11'1'1'1'111111•1'1111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII"'llii;;ipoolood00000u000000000000000000
111'11111111111k441alv 1114°'11'111 'Ii'lll 11111'Y'111'111111111111111111111111'11111111111 111111111111 111111111111 ' 1 l''''''''''iloodoohoolholooloolloolooloolooloolooloolou
111*, 1 1111h111111,1111111 1111111111111111,11111.101,11,111111,11,11.1111 1
lthoolooloolooloolo
111111111111111 11111111111101110 11,11,011 1
cawm����0�� .
a
mar health&wellness
PHYSICIAN CERTIFICATION STATEMENT FORM — Request for Transpo
This form provides LogistiCare or other authorized transportation provider with information on the appropriate level of
transportation needed for this Medi-Cal member.
Patient name:
Patient|D#KCUN #: Patient DOB: / /
Won'Eme,pemcv Medical Transportation (NEMT)
Choose one of the following levels of service:
OVVhae|cboirvoo OGwmoy/;ittervmn Ambulance: OALG OBLS OCCT
DAir transportation (requires prior authorization from the plan)
JUSTIFICATION: NEMT under Medi-Cal is covered only when the patient's medical and physical condition does not allow
him or her to travel by bus, passenger car, taxi, or other form of public or private conveyance.
NEMT requires a function limitation justification. The physician is required to document the patient's limitations and
provide specific physical and medical limitations that preclude the patient's ability to reasonably ambulate without
assistance or be transported by public or private vehicles.
What prevents the patient from traveling by bus, passenger car,taxi, or other form of public or private conveyance?
Non-Medical Transportation (NMT) ---
NMT includes transportation for medically necessary appointments and may be provided via taxi, sedan, paratransit (such as
Access), or fixed-route transportation, such as buses. No signature is required for NMT.
Choose one of the following levels of service:
DMass(public)transit 0Paratransit services(patient must qualify for services.) 0Sedan/taxi (curb-to-curb)
0Sedan (ambulatory door-to-door) 0 Sedan with folding wheelchair(patient is able to transfer without assistance) (curb-to-
ourb)
Duration of services (based on continued health plan eligibility): 030 days 060 days 090 days 01 Year
CERTIFICATION
The phii dentist or podiatristrwnpooaibWaforprovidhngoanafortbepmdemtisrespon»ib|efmrdeternmioingmedico|
necessity for transportation,This certificate can be completed and signed by a participating physician group(PPG),
independent practice association (IPA), primary care physician (PCP), MD, LVN, RN, PA, NP, CNM, PT, OT, ST, mental
health or substance use disorder provider, or discharge planner who is employed or supervised by the hospital, facility or
physician's office where the patient is being treated and who has knowledge of the patient's condition at the time of
completion of this certificate. PAs, NPs or CNMs may NOT sign this certificate for hospice care or home health care due to
restrictions listed below, NMT services do not require a physician signature and will be approved based on the least
costly method of transportation that meets the patient s needs
Restrictions:PA5,NPs and CNM5 maynot signponmnnmrmox:|mwnem=eredoorw,=vuvemms/rictivns/nTioe*2o/[umemFeue,a|
Regulations Section 440.70 for Home Health Services,Section 418.00 for Hospice Care or any other federal restriction for Medicaid
Staff/physician's name (print):
Staff/physician's signature: Title:
Date: Contact telephone: ( )
Please return form by fax to LogistiCare, Attention: Utilization Review at 1-877-457-3352.
18-387a/OTn020371s*oo