Documents

 TitleDescription 
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
DOH Introduction Letter List of Medicaid Covered Services in Nassau and Suffolk CountiesDownload
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
Logisticare Hospital Discharge ChecklistInformation needed by Logisticare when calling in and scheduling a discharge.Download
List of Medicaid Covered Service List of Medicaid Covered Services in Nassau and Suffolk CountiesDownload
Medicaid Transportation Request Fax Form With 2015 Attestation (called "Transportation Request Fax Form (3/5/15)")LogistiCare Transportation Request fax form, for multiple trips, with the 2015 attestation (called "Transportation Request Fax Form (3/2012)"). Gives space for naming the transportation provider.Download
NYDOH Approved Trip Reservation Call Script Call Script that will be used by LogistiCare agents during trip request intakeDownload
Nassau Suffolk DOH WebinarNon-Emergency Medical Transport WebinarDownload
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
Referral to Another Medical Site Transportation Request Fax FormMedical transportation request fax form to use when referring an enrollee to another medical practitioner.Download
What LogistiCare is responsible for.Key terms, phone numbers, and explanations for services provided by LGTC in Long IslandDownload
NYS DOH Care Plan Grid for Transportation of TBI Waiver ParticipantsCare Plan Grid required by NYS DOH to be submitted for Transportation of TBI Waiver Participants .Download
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