Ensuring that Medicaid recipients receive their entitled benefits, especially when transportation assistance is required, necessitates a systematized approach to documentation and verification. This is where the DMA-5118 form plays a crucial role. Crafted to bridge the communication between Medicaid-enrolled providers and the County Department of Social Services, this form acts as a certification that a Medicaid recipient has indeed availed of a Medicaid covered service from a Medicaid-enrolled provider on a specific date. The form requires detailed information, including the recipient’s name and Medicaid ID Number, the visit date, and the name of the Medicaid provider or facility, alongside the signature of the individual completing the form on behalf of the provider. This process not only ensures that Medicaid services are appropriately rendered and accounted for but also aids in maintaining the integrity of Medicaid's transportation assistance programs. Instituted on January 1, 2012, the DMA-5118 form is a critical piece in the audit trails, ensuring that the transportation assistance provided to Medicaid recipients is transparent, verifiable, and in direct correlation to the receipt of Medicaid-covered services.
| Question | Answer |
|---|---|
| Form Name | Form Dma 5118 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | DMA-5118, Handout, dma 5118a form, completing |
Handout 4
MEDICAID TRANSPORTATION
VERIFICATION OF RECEIPT OF MEDICAID COVERED SERVICE
TO: Medicaid Enrolled Provider
From: ___________________________ County Department of Social Services
When transportation assistance is provided to a Medicaid recipient, for audit purposes, it is necessary to document that the individual received a Medicaid covered service from a Medicaid- enrolled provider on the date of transport. Please complete the following:
This is to certify that __________________________________ visited this office or facility on
(Medicaid recipient’s name/Medicaid ID Number)
_________________________ and received a Medicaid covered service.
(date)
Name of Medicaid provider/facility: _______________________________________________
Signature of person completing form on behalf of provider: ____________________________
MEDICAID TRANSPORTATION
VERIFICATION OF RECEIPT OF MEDICAID COVERED SERVICE
TO: Medicaid Enrolled Provider
From: ______________________ County Department of Social Services
When transportation assistance is provided to a Medicaid recipient, for audit purposes, it is necessary to document that the individual received a Medicaid covered service from a Medicaid- enrolled provider on the date of transport. Please complete the following:
This is to certify that __________________________________ visited this office or facility on
(Medicaid recipient’s name/Medicaid ID Number)
_________________________ and received a Medicaid covered service.
(date)
Name of Medicaid provider/facility: _______________________________________________
Signature of person completing form on behalf of provider: ____________________________