Form Emedny 424601 – Fill Out and Use This PDF

Transportation Information Request Form

The following information must be provided to process your enrollment application. Failure to submit required information may result in your application being returned to you and will delay the enrollment process. Attach additional sheets when necessary.

1.Are you an out of state provider of medical services interested in participation for one occurrence of care delivered to one beneficiary?

Yes

No

If yes, indicate date of service: __________

If yes, do not continue completing this form, but you must sign the form on page 6.

2.Are you an out of state provider of medical services interested in participation for services to a beneficiary for a period up to a maximum of 60 days only?

Yes

No

Date of Service From ________ To _________

If yes, do not continue completing this form, but you must sign the form on page 6.

3.List the names of all other current or former companies or corporations owned or operated by any individuals listed in Section 1 of the Disclosure of Ownership and Control portion of your enrollment application, where the companies are or were Medicaid providers, Medicare providers, transportation providers, or providers of health care.

Company Name	FEIN or Provider Number	Owner(s) – include all owners
___________________	___________	________________________________
___________________	___________	________________________________
___________________	___________	________________________________

4.List the names of all other current or former companies or corporations owned or operated by a spouse, parent, child or sibling of any individuals listed in Section 1 of the Disclosure of Ownership and Control portion of your enrollment application, where the companies are or were Medicaid providers, Medicare providers, transportation providers, or providers of health care.

Company Name	FEIN/Provider #	Owner(s) – list relationship to Section 1 individual
___________________	___________	_________________________________________
___________________	___________	_________________________________________
___________________	___________	_________________________________________
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5.Are there any other Medicaid providers at your service address?

Yes ______	No _______
If yes, list the provider names:

____________________________________________________________________________

____________________________________________________________________________

6.List any professional licenses held by the owners. List even if licensed outside of New York State.

Last Name, First Name	Lic # (State)	Profession	NPI or Medicaid Provider #
__________________	_________	_________	_______________________
__________________	_________	_________	_______________________
__________________	_________	_________	_______________________

7.Do any of the owners operate a medical care institution (i.e. Nursing home, assisted living

facility, etc.)?

Yes

No ______

A. If yes:
Name of Facility	Type of Facility	Address	Provider #
_______________	_______________	___________________	_____________

B.Is the transportation cost included in their annual financial report to the Department of Health?

Yes ______

No ______

C.List categories of transportation that are included: ______________________________

8.Indicate the estimated percentage of services you provide in the following categories:

_____% Confined to wheelchair ____ % Ambulating with assistance _____% Fully ambulatory

9.Which geographic area(s) are you certified to serve by the Department of Transportation?

____________________________________________________________________________________

10.Indicate the exact days of the week and corresponding hours you provide transportation services:

Livery/Taxi _____________________________________________________________

Ambulette _____________________________________________________________

11.Estimate the percentage of business that will be billed to the NYS Medicaid Program: ____ %.

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14.Provide a history of past employment (5 years) for all owners, operation managers and office managers. (Use separate sheets of paper for each individual using the format below)

Name:

Position:(such as owners, office managers or operation managers. If owner serves as the office or operations manager, list accordingly.)

Name of Past Employer: (Name of company or individual)

Address:	(Full address including phone number)
Employment Dates:	(Start date to end date)
Nature of Duties:	(Must be specific)

15.Required information regarding leasehold arrangements. a. Business Location:

Indicate whether you rent or own the building at your service location. If you rent, indicate whether rent is paid in equal monthly or yearly installments. You must attach a signed copy of the current lease.

___________________________________________________________________________________

Submit a description of any other payments to be made as, or in lieu of, rent to the owner of the property.

___________________________________________________________________________________

Provide the name and address of the owner of the building(s) to be used by the business. If a corporation or partnership, list the names of the officers, directors, principal stockholders, partners, their social security numbers and any National Provider Identifiers or NYS Medicaid Program provider numbers or professional licenses held.

____________________________________________________________________________________

_____________________________________________________________________________________

Provide the name and address to whom the rent is paid. Attach a copy (front and back) of the most recent canceled rent check.

_____________________________________________________________________________________

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18.Have any of the owners ever been a subcontractor for a medical transportation provider?

YesNo

If yes, please provide the following:

Owner’s Name	Provider Name	NPI or NYS Medicaid Provider #
____________________	________________________	________________________________
____________________	________________________	________________________________

19.If this application is for a change of ownership or impending change of ownership, do you agree to pay all current and future liabilities that may be owed to the Medicaid Program by the entity that you have purchased or are purchasing as a result of an audit, investigation or other review?

Yes

No ______

Not an ownership change ___________________________

If yes, please attach a separate signed statement to that effect. The statement must be signed by the owner (buyer) listed below. (Please note that in some cases, an applicant for enrollment of a currently enrolled ambulette company must agree to assume liabilities as a condition of enrollment.)

Owner’s Name (print):	_____________________________________________________________
Owner’s Signature:	________________________________________	Date: __________
(Signature stamps are not permitted)
Application Prepared by (print): _________________________________		Date: __________
Telephone Number:	________________________________________

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