Form 13a9i) - Medicaid Transportation Reimbursement Form Page 2
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1
2State of New Hampshire
13A Web
Department of Health and Human Services
07/12
OMBP Use Only
F-___________ Auth:
F-___________ Auth:
F-___________ Auth:
MEDICAID TRANSPORTATION REIMBURSEMENT FORM
****INSTRUCTIONS ON BACK OF FORM****
PAYEE /RESOURCE INFORMATION
___ ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___
Key Name:
Resource #:
Payee Name (Enrolled Driver) and Address:
Relationship to
Service Code:
Recipient:
(Check One)
____________________________________________________
(Check one)
First
Last
_______________________________
____________________________________________
1. Self
(RT) Recipient
Mailing Address
Physical Address (If different than mailing)
Transporter
____________________________________ _________ __________________
2. Parent or
City/Town
State
Zip Code
Household Member
(VT) Volunteer
(
)
Transporter
Telephone #
________________________________________
3. Volunteer
RECIPIENT INFORMATION (person receiving Medicaid services)
___ ___ ___
___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
st
st
Recipient First Name (1
3 only)
Recipient Last Name (1
3 only)
Recipient Medicaid ID Number
TRIP INFORMATION
Recipient Transporter Trip Information
Volunteer Transporter Trip Information
From:
From:
___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___
(Volunteer’s Home Town/City)
(Zip Code
)
(Recipient’s Home Town/City)
(Zip Code
To:
)
OR
___ ___ ___ ___ ___ ___ ___ ___
To:
(Recipient’s Home Town/City)
___ ___ ___ ___ ___ ___ ___ ___
___ ___
To:
(Medical Provider’s Town/City )
(State
___ ___ ___ ___ ___ ___ ___ ___
___ ___
)
(Medical Provider’s Town/City)
(State)
$
.
$
.
___ ___ ___
___ ___
___ ___
___ ___ ___
___ ___
1. One Way Trip
2. Round Trip
Total Whole Miles Per Trip
Tolls/Parking/Bus
Receipts Verified
OMBP Use Only
(NO Decimals)
(Minimum $3.00, Receipts Required) OMBP Use Only
(Bus has no minimum)
Name of Enrolled NH Medicaid Provider & Facility/Group they work for:
_____________________________________________________________
Medical Provider Type Code:
(See list below in shaded area)
_____________________________________________________________
Address of Medicaid provider where services were rendered
_____________________________________________________________
Medical Provider Type Codes: [1] Hospital
[4] Therapies (Physical/Speech/Occupational) [7] Pharmacy
,
(Select Carefully
[2] Physician/Mental Health Provider
[5] Dialysis
[A] Medicaid Use Only
see instructions)
[3] Dentist
[6] Referral/Specialist *** (See back of form) [B] Bus Transportation with receipts
***
Medical Provider/Pharmacy Signature & Date (must be signed on date of service)
Trip Date (MM/DD/YY)
I certify that NH Medicaid covered services were rendered for this recipient on the trip date
indicated.
/
_______
___ ___
___ ___ /___ ___
_______
___
_______
* CPT/CDT Code
Signature
Today’s Date
If Pharmacy, do you provide free delivery to recipient’s residence?
Yes
No
Is the RX covered by Medicare Part D?
Yes
No
***
***
***This is to certify that the information above is true, accurate and complete. I understand that payment of this claim may be from Federal
and State funds and that any false claims, statements, documents or the concealment of material fact may be prosecuted under applicable
Federal and State Laws.
Recipient Signature:
Date:
Payee Signature:
Date:
Send original to Medicaid Transportation
Please keep a copy for your records
SR 99-46
(3YC)
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