Instructions To Complete Enrollment Form For Transportation (Page 4 of 4) in pdf

Instructions To Complete Enrollment Form For Transportation Page 4

Attestation for Non-Medical Transportation Providers

New York State Medicaid Program

My signature below confirms the understanding that any licensure requirements in the

municipalities where a provider/vendor may operate are the provider’s/vendor’s sole

responsibility. Neither the State Department of Health nor the Department’s contracted

transportation manager will be responsible for penalties incurred by a provider/vendor due to

unmet local licensure requirements. In addition the provider/vendor agrees to maintain

records which document that drivers possess a valid commercial driver’s license (Class E) and

that vehicles are registered with livery license plates.

Successful enrollment is not a guarantee of trip assignments. Medicaid trips are

assigned based upon expressed choice among participant transportation vendors, by the

Medicaid enrollee or, where the enrollee expresses no choice, the medical practitioner; and

finally, where no choice is expressed, by rotation. Further, if successfully enrolled as a New

York State Medicaid transportation provider/vendor, you agree to comply with all of the

requirements and quality standards of such a vendor as detailed in the Transportation Provider

Policy Manual, Medicaid Provider Manual and Title 18 of the New York Codes, Rules and

Regulations, as well as administrative requirements of the Department and its transportation

manager (where applicable).

__________________________________________

Signature of Owner

Date

EMEDNY-424402 (03/17)

Instructions To Complete Enrollment Form For Transportation Page 4