Form Dma-5124 - Medicaid Transportation Provider Documentation - North Carolina Department Of Social Services
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1
2Medicaid Transportation Provider Documentation
North Carolina _____________________County Department of Social Services
Organization Information
Organization Name as shown on income tax return__________________________________________EIN_______________________________
Doing Business As (DBA) information
DBA Name_______________________EIN_____________ Former DBA Name(s)______________________________EIN__________________
Former DBA Name(s)______________________________EIN__________________
Years Doing Business under Current Name______________________Years Doing Business under Previous Name(s)_______________________
Ownership Information
How would you describe the ownership? (circle one)
Sole Proprietor
Partnership
Single –Owner LLC
Corporation
City/Municipality
Non-Profit
For Corporation, Partnership, or Non-Profit: P lease provide ownership information for each owner who has direct or indirect ownership
or control interest of 5% or more in the organization or entity.
Owner 1
Full Name (Last, first, Middle)_______________________________________ SSN or EIN____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
Owner 2
Full Name (Last, first, Middle)_______________________________________ SSN or EIN ____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
Owner 3
Full Name (Last, first, Middle)_______________________________________ SSN or EIN____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
Owner 4
Full Name (Last, first, Middle)_______________________________________SSN or EIN ____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
Managing Relationships
As required by 42 CFR 1002.3, Non Emergency Medical Providers must disclose the following for each individual officer, director, managing
employee (general manager, business manager, administrator) and Electronic Funds Transfer (EFT) authorized individual. Failure to provide the
required information may result in a denial for participation.
Relationship 1
Full Name (Last, first, Middle)_______________________________________ Social Security Number____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
Relationship 2
Full Name (Last, first, Middle)_______________________________________ Social Security Number____________________________________
Date of Birth (MM/DD/CCYY)___________________Business Relationship to NEMT Provider___________________________________________
Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.)___________________________________________________
DMA-5124 (revised 6/6/12)
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