Medicaid Non-Emergency Medical Transportation (NEMT):  Ride Request Forms 

You can now download fillable forms to request a ride or apply for a bus pass!  The information below will help you complete the forms.

 

Service Request Form

To request rides for up to three medical appointments, you can use the Service Request Form.  Facilities like nursing homes and medical offices will find this form useful for requesting rides for their clients, but you can also use the form if you are requesting a ride for yourself—simply leave the Facility and Coordinator lines blank.  Using the check boxes on the form, you can identify the type of service you are requesting: Fuel Voucher, Bus Pass, or “Ride” (taxi, wheelchair van, etc.).

 

If you are requesting a fuel voucher, please provide us with a copy of your driver’s license (If you will not be driving yourself, please provide a copy of the driver’s license of the person who will be driving for you), vehicle registration, and proof of vehicle insurance.

 

If you are requesting a bus pass, please note under “Other Comments” whether you need an adult pass, youth pass, reduced fare pass, or paratransit/VIP.  If you would like a bus pass for several appointments during a month, please complete and return a Bus Pass Application form (see below).

 

Once we have scheduled your ride, we will complete the form’s “Confirmation” section and will fax the form back to you.  If a ride will be provided to you by one of our community providers, such as a taxi company, you will see your ride pick-up time and the name of your ride provider under the “Confirmation”. If you have not heard back from us at least two working days before your appointment, please call our office to verify that we have received your request. 

 

Click here for a printable Service Request Form or you can find a fillable version attached at the bottom of this page.

 

Bus Pass Application

You can use the Bus Pass Application to request a bus pass for several single appointments or “repeating appointments.”  “Repeating appointments” are appointments with the same medical provider that are on the same day and time from week to week, such as dialysis or counseling appointments.  Please be sure to write legibly and always include a telephone number where we can reach you.  You can mail or fax your application.  Please submit your application at least seven business days before your first appointment to allow our staff time to process and return your bus pass.  Bus passes are issued beginning on the 20th of the month prior to your appointment. 

 

Click here for a printable Buss Pass Form or you can find a fillable version attached at the bottom of this page.

 

Deadlines for Service Requests

Fuel Voucher:  Requests may be submitted one month in advance and must be received at least two business days before your medical appointment.

 

Bus Pass: Please submit requests for bus passes in sufficient time for processing.  Please allow at least seven business days from the date you submit your bus pass request for us to process and mail your bus pass to you. 

 

Rides (taxi, wheelchair van, etc.): Please be sure that you complete and fax the form at least two business days before your medical appointment.  You can fax the form up to a month in advance. 

 

ð  Remember, the more time you give us to arrange your ride, the more time we will have to clear up any questions we may have about your service request and the better we can serve you! 

 

Directions for Form Use 

To fill out either form onscreen, select Download, then Open.  This displays the fillable version of the form.  To proceed, enter information in each applicable field.  Use your mouse or Tab key to move the cursor through the form.  Also, you can copy and paste information onto the form from other documents. 

 

When completed, print and sign the form (if required) and fax or mail to SMS.  (Confidentiality and security requirements prevent us from accepting e-mail requests.)

 

Note:  You can also print a blank form and fill it out by hand.

 

To download and save a form to your local machine, select Download, then Save.

 

 

 

 

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Beth Mulcahy,
May 9, 2011, 2:28 PM
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Beth Mulcahy,
May 9, 2011, 2:29 PM