I certify that my attending/referring physician or primary care provider, , who is a certified Medicaid provider, has referred me to receive care at the stated destination listed in Section 3. I understand that this transportation is funded through the Non-Emergency Medical Transportation (NEMT) benefit of Health First Colorado (Medicaid) and is only available for medically necessary appointments.

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby authorize Peak Family Transport LLC and its employees, contractors, and agents to use and disclose my protected health information (PHI) for the following purposes, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Colorado state privacy laws:

(1) Insurance Claims and Billing: To submit claims to Health First Colorado (Medicaid), insurance carriers, and other third-party payers for Non-Emergency Medical Transportation (NEMT) services provided to me.

(2) Appointment Coordination: To communicate with my healthcare providers, medical facilities, and authorized representatives regarding appointment times, scheduling, availability, confirmation, and cancellation of transportation services.

(3) Transportation History: To maintain records of my appointment history, transportation services provided, trip dates, destinations, and related service documentation as required by Colorado Medicaid NEMT regulations.

(4) Medical Necessity Verification: To verify medical necessity of transportation with my healthcare providers, including discussion of my medical condition as it relates to my inability to use other means of transportation.

(5) Care Coordination: To share information with healthcare providers, Medicaid representatives, and other entities as necessary to coordinate my care and ensure appropriate transportation services.

I understand that the information disclosed may include medical records, appointment details, diagnosis codes, provider information, and other health information necessary for Peak Family Transport LLC to provide NEMT services and obtain payment for such services. I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. I understand that Peak Family Transport LLC will not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. This authorization shall remain in effect until I revoke it in writing or for a period of one (1) year from the date signed below, whichever occurs first.

I, , do hereby certify and attest, under penalty of perjury, that:

(1) The destination address stated in this form is the actual location where I am traveling, and I am not falsifying my destination for the purpose of obtaining transportation benefits under the Health First Colorado NEMT program.

(2) The purpose of this trip is solely for a medically necessary appointment as referred and authorized by my primary care provider or treating physician, , who is a certified Colorado Medicaid provider professional.

(3) All information provided in this form is true, accurate, and complete to the best of my knowledge.

(4) I have no other available means of transportation and I qualify for NEMT services under the Health First Colorado program.

(5) If travel exceeds 50 miles one way, I certify that the reason selected above accurately reflects why care cannot be obtained from a closer provider.