Form - Dfa-Nemt-1a - Supplement To Application For Nemt Reimbursement Program Page 2
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2VERIFICATION OF TRAVEL AND ATTENDANCE FOR NEMT
For DHHR Use Only:
MA ID ____________________________
Medical Provider: Do not sign if the medical service/treatment
Driver’s VN
_______________________________
is not billable or billed to the Medicaid Program.
Patient’s Name
___________________________________________________
SSN ___________________________
Initial
Purpose of Visit:
Routine
Follow-up
Walk-in
Name and Address of Medical Provider
_____________________________________________________________________
Date of Appointment ______________________________________________
Time of Appointment __________________
________________________________________________________________________________
_________________
Signature of Medical Provider or Authorized Representative
Date
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Transportation Provider:
Private Vehicle
Taxi
Bus
Plane
Community Van
Other
___________________________________________________________________
____________________________
Driver’s/Carrier’s Name (Please print)
SSN or Tax ID
Driver’s Signature ____________________________________________________
Date ______________________
Mailing address__________________________________________________________
Phone _____________________
Private Vehicle Cost: Mileage________ Parking _________Tolls _________
Common/contract Carrier: Round-trip fare __________________
For DHHR Use Only:
Lodging: Cost per night _________ Number of nights_________
Miles ______X______=________
Meals: Number of persons_________ Number of meals per person_________
Total lodging ________________
Other costs _________________
Total for this trip _____________
(Receipts must be attached for lodging, parking and common carrier fare.)
VERIFICATION OF TRAVEL AND ATTENDANCE FOR NEMT
For DHHR Use Only:
MA ID ____________________________
Medical Provider: Do not sign if the medical service/treatment
Driver’s VN
_______________________________
is not billable or billed to the Medicaid Program.
Patient’s Name
___________________________________________________
SSN ___________________________
Initial
Purpose of Visit:
Routine
Follow-up
Walk-in
Name and Address of Medical Provider
_____________________________________________________________________
Date of Appointment ______________________________________________
Time of Appointment __________________
________________________________________________________________________________
_________________
Signature of Medical Provider or Authorized Representative
Date
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Transportation Provider:
Private Vehicle
Taxi
Bus
Plane
Community Van
Other
___________________________________________________________________
____________________________
Driver’s/Carrier’s Name (Please print)
SSN or Tax ID
Driver’s Signature ____________________________________________________
Date ______________________
Mailing address__________________________________________________________
Phone _____________________
Private Vehicle Cost: Mileage________ Parking _________Tolls _________
Common/contract Carrier: Round-trip fare __________________
For DHHR Use Only:
Lodging: Cost per night _________ Number of nights_________
Miles ______X______=________
Meals: Number of persons_________ Number of meals per person_________
Total lodging ________________
Other costs _________________
Total for this trip _____________
(Receipts must be attached for lodging, parking and common carrier fare.)
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