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Title
Description
Nassau and Suffolk County Transportation Providers
Transportation Providers servicing Nassau and Suffolk Counties
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Referral to Another Medical Site Transportation
Nassau and Suffolk County Medicaid trip order form
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TripCare Form-e2015 FAQ .pdf
TripCare Form-e2015 FAQ .pdf
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Medicaid Transportation – Verification of Medicaid Transportation Abilities (Form-2015) Policy and Procedure
Medicaid Transportation – Verification of Medicaid Transportation Abilities (Form-2015) Policy and Procedure
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Long Island Medical Practitioner Letter
NYS DOH Medical Practitioner Letter
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Facility Services Web Portal Admin User Form
Request Form to Setup an Administrator Account for Requesting Transportation Online
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Form 2015, Medical Justification (Adobe PDF format)
Medicaid Transportation Justification Request Form. There is no trip information on this form.
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Standing Order Request Form with Treatment Types DOH Revisited 04-16-15.
To request NEMT for fee for service enrollees needing regularly reoccurring transport one or more times per week for one or more months duration to a Medicaid covered service. Has 2015 attestation, and space to name the transportation provider.
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Modivcare Hospital Discharge Checklist
Information needed by Modivcare when calling in and scheduling a discharge.
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List of Medicaid Covered Service
List of Medicaid Covered Services in Nassau and Suffolk Counties
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NYDOH Approved Trip Reservation Call Script
Call Script that will be used by ModivCare agents during trip request intake
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Quick Reference sheet for facilities.
Facility handouts for enrollees in 4 languages
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Long Island Requirements for the Quality of Transportation Services.
Requirements for participation as a Medicaid Transportation Provider.
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What Modivcare is responsible for.
Key terms, phone numbers, and explanations for services provided by Modivcare in Long Island
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NYS DOH Care Plan Grid for Social & Non-Medical Transportation by TBI & HARP enrollees
Care Plan Grid required by NYS DOH to be submitted for Transportation of TBI Waiver & HARP Participants
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Social Transportation Guidance for the Traumatic Brain Injury (TBI) Waiver Program
Guidelines for Approving Requests for Social Transportation of Persons Enrolled in the Traumatic Brain Injury (TBI) Waiver Program.
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List of Medicaid Covered Services.
List of Medicaid Covered Services in Nassau and Suffolk Counties.
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Outside Common Medical Market Area Form
NYDOH .form necessary to approve trip requests Outside the Nassau and Suffolk Counties Medical Market Area
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