Fillable MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED (North Carolina)

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MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED (North Carolina)

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DMA-5118A (New 1-15)
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 ______________________________________________________
(Medicaid recipient’s name/Medicaid ID Number)
visited this office or facility on ________________ and received a Medicaid covered service.
(date)
Name of Medicaid provider/facility: ______________________________________________
Name of individual completing form (please print) ___________________________________
Phone number of person completing form ________________________
Signature of person completing form: ____________________________________________
Note: The County has the authority to administer the Medicaid program for the North
Carolina Department of Health and Human Services Division of Medical Assistance
pursuant to N.C.G.S. 108A-25 and rules adopted by the State of North Carolina.
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MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED (North Carolina)

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Completed 1 February 2022

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