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DOUGLAS COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES MEDICAL TRANSPORTATION PROGRAM VERIFICATION FORM (Use a new form each month) MEDICAL CAB SERVICE IS NOT AVAILABLE TO HOUSEHOLDS WITH VEHICLE ASSET MEDICAL TRANSPORTATION FOR THE MONTH MEDICAL FACILITY DATE & TIME OF APPOINTMENT SIGNATURE OF MD/RN/ASSISTANT OR FACILITY STAMP *(EXAMPLE) NAME OF CLINIC (DATE/TIME OF APPT.) (DOCTOR’S SIGNATURE) Required Required Required ALL INCOMPLETE FORMS WILL BE RETURNED AND WILL NOT BE CONSIDERED VERIFICATION. ALL FORMS WITH MORE THAN ONE MONTH OF VERIFICATION ON IT WILL BE RETURNED. PLEASE TURN IN THIS VERIFICATION FORM AT THE END OF EACH MONTH, NO LATER THAN THE 5TH OF THE FOLLOWING MONTH TO: DOUGLAS COUNTY HEALTH & HUMAN SERVICES 1316 N 14TH STREET, SUITE 400 ~ ATTN: MEDICAL TRANSPORTATION ~ SUPERIOR, WI 54880 OR YOU CAN FAX YOUR FORM TO: [PHONE REDACTED] ~ ATTN: MEDICAL TRANSPORTATION (IF YOUR VERIFICATION FORM IS NOT RECEIVED, YOUR NAME WILL BE PLACED ON THE NO RIDE LIST) YOU CAN REQUEST MORE FORMS AT THE ABOVE ADDRESS OR THROUGH THE MEDICAL TRANSPORTATION MESSAGE LINE – [PHONE REDACTED] RAM 10/2008