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Form Dma-5124 - Medicaid Transportation Provider Documentation - North Carolina Department Of Social Services Page 2

Relationship 3

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 4

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.)___________________________________________________

By my signature, I attest that none of the individuals identified above have ever been convicted of:

•

A criminal offense related to the delivery of an item or service under Medicare, Medicaid, or any state health care program;

•

Medicare/Medicaid or any other healthcare program fraud;

•

A conviction related to patient/client abuse;

•

A felony conviction related to a controlled substance occurring after August 21, 1996.

Name____________________________________________________Signature_____________________________________________________

Date_____________________________________________________

Results of OIG Federal Inquiry:

Circle One:

No Match Found

Organization or Business

Owner

Manager

Name of individual/entity which resulted in an exclusion match____________________________________________________________________

Exclusion Code__________________

Transportation Coordinator/Designee Signature________________________________________________________________________________

Date_____________________________________________________

https://providertracking.dhhs.state.nc.us/default.aspx

Results of NC DHHS Provider Penalty Tracking Database

Circle One:

No Match Found

SSN

Owner

Name of owner and/or SSN of owner which resulted in an exclusion match__________________________________________________________

Exclusion Reason (Action Issued)___________________________________________________________________________________________

Transportation Coordinator/Designee Signature________________________________________________________________________________

Date_____________________________________________________

DMA-5124 (revised 6/6/12)

Form Dma-5124 - Medicaid Transportation Provider Documentation - North Carolina Department Of Social Services Page 2