INSTRUCTIONS FOR FORM 14
MEDICAL TRANSPORTATION ENROLLMENT FORM
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.
***SHADED AREAS ON FORM 14 ARE FOR STATE USE ONLY ***
**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*****************