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Long Island Medical Practitioner Letter
NYS DOH Medical Practitioner Letter
Nassau and Suffolk County Transportation Providers
Transportation Providers servicing Nassau and Suffolk Counties
Referral to Another Medical Site Transportation
Nassau and Suffolk County Medicaid trip order form
Facility Services Web Portal Admin User Form
Request Form to Setup an Administrator Account for Requesting Transportation Online
Form 2015, Medical Justification (Adobe PDF format)
Medicaid Transportation Justification Request Form. There is no trip information on this form.
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.
ModivCare Hospital Discharge Checklist
Information needed by ModivCare when calling in and scheduling a discharge.
List of Medicaid Covered Service
List of Medicaid Covered Services in Nassau and Suffolk Counties
NYDOH Approved Trip Reservation Call Script
Call Script that will be used by ModivCare agents during trip request intake
Quick Reference sheet for facilities.
Facility handouts for enrollees in 4 languages
Long Island Requirements for the Quality of Transportation Services.
Requirements for participation as a Medicaid Transportation Provider.
What ModivCare is responsible for.
Key terms, phone numbers, and explanations for services provided by ModivCare in Long Island
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
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.
List of Medicaid Covered Services.
List of Medicaid Covered Services in Nassau and Suffolk Counties.
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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