Documents

 TitleDescription 
Long Island Medical Practitioner LetterNYS DOH Medical Practitioner LetterDownload
Nassau and Suffolk County Transportation ProvidersTransportation Providers servicing Nassau and Suffolk CountiesDownload
Referral to Another Medical Site TransportationNassau and Suffolk County Medicaid trip order formDownload
Facility Services Web Portal Admin User FormRequest Form to Setup an Administrator Account for Requesting Transportation OnlineDownload
Form 2015, Medical Justification (Adobe PDF format)Medicaid Transportation Justification Request Form. There is no trip information on this form.Download
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.Download
ModivCare Hospital Discharge ChecklistInformation needed by ModivCare when calling in and scheduling a discharge.Download
List of Medicaid Covered Service List of Medicaid Covered Services in Nassau and Suffolk CountiesDownload
NYDOH Approved Trip Reservation Call Script Call Script that will be used by ModivCare agents during trip request intakeDownload
Quick Reference sheet for facilities.Facility handouts for enrollees in 4 languages‎ Download
Long Island Requirements for the Quality of Transportation Services.Requirements for participation as a Medicaid Transportation Provider.Download
What ModivCare is responsible for.Key terms, phone numbers, and explanations for services provided by ModivCare in Long IslandDownload
NYS DOH Care Plan Grid for Social & Non-Medical Transportation by TBI & HARP enrolleesCare Plan Grid required by NYS DOH to be submitted for Transportation of TBI Waiver & HARP ParticipantsDownload
Social Transportation Guidance for the Traumatic Brain Injury (TBI) Waiver ProgramGuidelines for Approving Requests for Social Transportation of Persons Enrolled in the Traumatic Brain Injury (TBI) Waiver Program.Download
List of Medicaid Covered Services.List of Medicaid Covered Services in Nassau and Suffolk Counties.Download
Outside Common Medical Market Area FormNYDOH .form necessary to approve trip requests Outside the Nassau and Suffolk Counties Medical Market AreaDownload