Form Dma-5125b - Medicaid Transportation Suspension Notice - North Carolina Department Of Social Services

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Medicaid Transportation Suspension Notice
North Carolina _____________________County Department of Social Services
_______________________Date
____________________________
____________________________
____________________________
____________________________
Our records indicate that you were a No-Show for scheduled Medicaid Transportation trips on
the following dates: ____________________, ___________________, and
___________________.
As a recipient of Medicaid transportation, you must comply with the Medicaid Transportation
No-Show policy. The Medicaid Transportation No-Show policy was explained/given to you on
____________________, after you had the first No-Show for a scheduled transportation trip.
A Final Notice was explained/given to you on __________________ after you had a second No-
Show for a scheduled trip, informing you that the next No-Show for a scheduled transportation
trip, without a good cause, may result in suspension of medical transportation services for a
period of thirty days.
This notice is to inform you that your Medicaid Transportation services have been suspended
from ___________________ to ___________________. You may still request transportation to
the following critical service __________________________________ (does not apply if blank)
during this time period. For services other than the one indicated above, you can call and request
Medicaid Transportation to be provided after ____________________.
If you disagree with this decision or have a good reason for your No-Shows, you may request an
appeal by calling the Transportation Coordinator at _______________________.
_______________________________
Transportation Worker Signature
DMA-5125B
5/1/2012

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