Medicaid Transportation Enrollment Form


14(ii) web
Enrollment Instructions for Medical Transportation Payees:
**Please check whether this is a new enrollment or whether you’re making a change to your information on file. If
you have moved please be sure to list the date of your move.
Do you wish to enroll as: (Place a check mark in the appropriate box on Form 14) See below for appropriate selection.
Recipient Transporter: Select this option if you transport either yourself (if you are Medicaid eligible) and/or a
Medicaid eligible recipient who resides in your household or your child regardless of where they live (minor or
adult). Select this option if you take the bus and need reimbursement.
Volunteer Transporter: Select this option if you are transporting someone outside of your household, who is not
your child (minor or adult). If you are a Volunteer Transporter, you must use your own vehicle. You must provide
a copy of your current driver’s license and proof of automobile liability insurance that states the effective date and
expiration date of the insurance. ***If you do not provide this information, enrollment cannot be completed
and payment cannot be made.
Payee’s Name: Enter your name, or business name as registered with the IRS, in last name, first name order. Leaving a
space between your last and first name and between words in your business name.
Payee’s Telephone Number: Enter your telephone number including your area code or a telephone number where you
can be reached. Entry should include the area code and be in xxx-xxx-xxxx format. This field must be completed in
order for payment to be made.
Mailing Address/PO BOX: Enter your street address or PO Box, including the City or Town, State and Zip Code,
leaving a blank space between numbers and words.
Physical Address: Enter your physical address, if different than your mailing address, including the City or Town,
State and Zip Code, leaving a blank space between numbers and words.
Payee’s Social Security Number or Payee’s Federal ID Number : Enter either your Social Security Number or your
Federal ID. Social Security number should be in xxx-xx-xxxx format, federal identification number should be in xx-
xxxxxxx format. One of these fields must be completed in order for payment to be made.
I have read and understand the Summary Form (930) for the program: You must read the form and indicate yes
here in order to be enrolled into the program. ***If you have questions please call us.*****
Payee Signature: Payees must sign and date Form 14.
**Mail completed Form 14 and copies of any required documentation to: Medicaid Transportation, 129 Pleasant
Street, Thayer Building, Concord, NH 03301-8575.
Keep a copy of the completed Form 14 for your records.
When enrollment is complete, you will receive a computer-generated document, which will provide you with your key
name and resource number(s). This information is very important, as it is required on every claim form you submit for
payment. ***Please allow up to 3 weeks for processing.
Medicaid Transportation Office: (800) 852-3345 extension 3770 or (603) 271- 3770
(800) 852-3345 extension 4344 (then extension 115) or (603) 271-4344 extension 115
*****************Please contact us if you have any questions*****************
SR –99-46


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