Fillable Non Emergency Transportation Provider (Arizona Health Care Cost Containment System)

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Non Emergency Transportation Provider (Arizona Health Care Cost Containment System)

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PROVIDER TYPE PROFILE
PROVIDER
TYPE
28
NON-EMERGENCY TRANSPORTATION PROVIDERS
REIMBURSE-
MENT TYPE
02
FEE FOR SERVICE
EFFECTIVE 10/01/1982
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY
31
NON-EMERGENCY
TRANSPORTATION
PROOF OF VEHICLE INSURANCE
COPY OF ONLINE TRAINING
CERTIFICATE
COPY OF REGISTRATION FOR EACH
VEHICLE REQUIRED
COMPANY’S NAME AND LOGO MUST BE
ON ALL VEHICLES
COPY OF CPR AND FIRST AID CARD FOR
EACH DRIVER
COMPLETED DRIVER INFORMATION
PROFILE
HIPPA TRAINING ANNUALLY, PROOF
WILL BE VERIFIED ON SITE VISIT
SERVICES PROVIDED ON RESERVATION
MUST SUBMIT COPY OF TRIBAL
BUSINESS LICENSE
TAXI COMPANIES MUST SUBMIT A COPY
OF THEIR LICENSE FROM THE
DEPARTMENT OF WEIGHTS AND
MEASURES.
As the Owner/Provider you are responsible for maintaining and providing upon request a
valid Arizona drivers license for each driver and proof of insurance, CPR and First Aid
cards, & HIPPA training documents.
As part of the registration process the Owner/Provider is required to disclose each
employee’s name, employment begin date, employment end date (if applicable), date of
birth, and social security number information using the 2
nd
page of this form.
Any changes to the above must be reported within 30 days.
By signing below you are indicating that this information will be kept on file and made
available upon request.
Company Name ID Number: ____________
Signature_________________________________ Date_____________________
SPECIAL INSTRUCTIONS: ALL NON-EMERGENCY TRANSPORTATION SERVICES GREATER THAN
100 MILES REQUIRE PRIOR AUTHORIZATION. FOR PRIOR AUTHORIZATION OF FFS CLAIMS,
CALL 1-800-433-0425.
REVISED 1/9/2015
NON EMERGENCY DRIVER INFORMATION
PROVIDER
TYPE
28
NON-EMERGENCY TRANSPORTATION *(Page 2 of 2)
COMPANIES ONLY
REIMBURSE-
MENT TYPE
02
FEE FOR SERVICE
EFFECTIVE 10/01/1982
List of Employees
(ALL FIELDS ARE MANDATORY)
Last Name:
First Name, Middle Initial:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Last Name:
First Name, Middle Initial:
Employment Begin Date:
Employment End Date:
Date of Birth: (MM/DD/YYYY)
Copy if additional pages are needed. REVISED 1/9/2015
This information is required in accordance with 42 CFR 455 Subparts B and E and State Medicaid Director Letters
08-003 & 09-001.
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Non Emergency Transportation Provider (Arizona Health Care Cost Containment System)

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Completed 22 July 2020

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