Medicaid Transportation Enrollment Form printable pdf download

14(ii) web

07/12

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*****************

SR –99-46

Medicaid Transportation Enrollment Form