Form Dma-5047 - Medicaid Transportation Assessment
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1
2Medicaid Transportation Assessment
Section A: Identifying Information
Casehead Name _____________________________________ County Case #______________________
Date of Initial Request/Assessment: _____________________
Mailing Address ________________________________
Physical Address: ___________________________
________________________________
___________________________
Phone: ______________________
________________________
____________________________
Home
Work
Other
Recipient Name
Medicaid ID #
Program/Category
Presumptive Eligibility #
Medicaid Denied
Authorized
NEMT Approved
Date DMA-5024
Reason _________
Medicaid Cert. Period
NEMT Denied
provided to A/R_________
____________
Reason______________
Recipient Name
Medicaid ID #
Program/Category
Presumptive Eligibility #
Medicaid Denied
Authorized
NEMT Approved
Date DMA-5024
Reason _________
Medicaid Cert. Period
NEMT Denied
provided to A/R_________
____________
Reason______________
Recipient Name
Medicaid ID #
Program/Category
Presumptive Eligibility #
Medicaid Denied
Authorized
NEMT Approved
Date DMA-5024
Reason _________
Medicaid Cert. Period
NEMT Denied
provided to A/R_________
____________
Reason______________
Recipient Name
Medicaid ID #
Program/Category
Presumptive Eligibility #
Medicaid Denied
Authorized
NEMT Approved
Date DMA-5024
Reason _________
Medicaid Cert. Period
NEMT Denied
provided to A/R_________
____________
Reason______________
Recipient Name
Medicaid ID #
Program/Category
Presumptive Eligibility #
Medicaid Denied
Authorized
NEMT Approved
Date DMA-5024
Reason _________
Medicaid Cert. Period
NEMT Denied
provided to A/R_________
____________
Reason______________
Section B: Assessment of the A/R’s Need for Transportation
1. Do you have access to a vehicle that can be used to get to and from your medical appointments?
Yes
No
Sometimes (Explain) ____________________________________________________________________
2. How have you been getting to your medical appointments? (Check all that apply)
Drive yourself
Friend/relative provides transportation
Bus/Taxi
Transportation services from an agency such as DSS, Health Department, Council on Aging, etc.
Name of agency ________________________________________________________________
3. Do you live within walking distance of a bus or van route?
Yes
No
DMA-5047
1
Rev. 01/01/2012
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