Medicaid Transportation Provider Enrollment Form
Complete this form to enroll as a Medicaid transportation provider for non-emergency transportation services.
Provider Information
Provider or Company Name
*
Business Type / Entity Type
*
Sole Proprietor
LLC
Corporation
Partnership
Nonprofit
Other
Primary Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Business Website (if available)
Service Capacity and Operations
Service area covered
*
County
Region
Other
Transportation services offered
*
Wheelchair-accessible transport
Stretcher transport
Ambulatory transport
Non-emergency medical transportation
Other
Number of vehicles available
*
Operating hours and days
*
Can you meet scheduled and recurring ride requests?
*
Yes
No
Compliance and Enrollment Attestation
Commercial liability coverage maintained
*
Yes — required coverage is maintained
No
Vehicle safety and maintenance compliance
*
Yes
No
Staff/background screening or driver training completed, if applicable
*
Yes
No
Not applicable
Attestation of accuracy and agreement to Medicaid transportation provider requirements
*
I certify that the information provided is accurate and complete and that I agree to follow Medicaid transportation provider requirements and enrollment terms
Submit Enrollment
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