Section 8 – The signature of the physician, dental third-party administrator, physician’s assistant, nurse midwife, dentist, nurse practitioner, psychologist, or managed-care representative is required to process the PT-1 form. The signature certifies that the information contained on the form and any attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete to the best of the signatory’s knowledge. Any falsification, omission, or concealment of any material fact contained on this form may result in civil penalties or criminal prosecution.
For more detailed information about the MassHealth transportation benefit, consult the MassHealth transportation regulations at 130 CMR 407.000. If you have any questions about completing this form, please call the MassHealth Transportation Authorization Unit at MassHealth Customer Service at 1-800-841-2900.