Parent/Guardian Of

Parent/Guardian of:

Re: Parental Authorization

Minnesota Non-Emergency Transportation (MNET) requires a parent or legal guardian to sign a Parental Authorization to allow any minor, under 18 years of age, to receive Access Transportation Services (ATS) to non-emergency medical appointments without accompaniment of an adult.

ATS is a curb to curb or door to door service that is provided by the transportation company transporting the minor to and from MA approved appointments

MNET must receive the signed Parental Authorization prior to scheduling any transportation for a minor traveling without an adult. Once received, the signed authorization is valid for one year from the signature date.

Please return the signed ATS Parental Authorization form to MNET via mail or fax

Contact MNET’s Customer Service Department at 1-866-467-1724 with any questions or concerns.

MNET Customer Service Department

Send correspondence to: MNET Attn: Customer Service Department 1110 Centre Pointe Curve Suite 220 Mendota Heights, MN 55120

Fax: 651-203-1262

Minor ATS Parental Authorization

Minor Recipient: MA Number:

I, ______, parent or legal guardian of ______, authorize MNET to schedule transportation for my minor dependent, under 18 years of age, to and from their medical appointments. I understand that this authorization will allow an ATS Transportation Provider, of my choice, to transport my minor dependent to and from Minnesota Health Care Program (MHCP) approved appointments without accompaniment of a parent or legal guardian.

I have read and understand the Parental Authorization document. Therefore, I authorize MNET to schedule non-emergency medical transportation for my minor dependent mentioned above.

The Parental Authorization is valid for one year from the signature date.

______Print Name Parent/Legal Guardian

______Signature Parent/Legal Guardian Date

______Emergency Contact Name

______Emergency Contact Phone Number

*Note: It is imperative an emergency contact is provided to MNet while approved transportation providers are in possession of your minor recipient. In the event that you choose not to provide this information to MNet and all other means to contact a guardian for the minor recipient are exhausted, your child will be left in the custody of the nearest authority. ______

Fax or Mail signed consent form to: MNET Customer Service Department 1110 Centre Point Curve, Suite 220 Mendota Heights, MN 55120 Fax: 651-203-1262