Get Non Emergency Medical Transportation Nemt Payment Authorization Form 2020-2025

Filling out the Non Emergency Medical Transportation (NEMT) Payment Authorization Form online can streamline your application process and ensure you receive the necessary support for non-emergency transportation. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete your form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the appropriate option to indicate whether this is your first time completing the NEMT Payment Authorization Form or if you are making changes to a previously submitted form. This is important as it helps in processing your request accurately.
3. Complete the Payee Information section at the top of the page. Provide your name, mailing address, city, state, zip code, and daytime telephone number. If you know your NEMT provider number, include that as well.
4. Identify one household member as the payee by entering their name, date of birth, and Social Security Number or Tax ID Number. This information is crucial for proper identification.
5. For electronic payment options, select only one method of payment by checking the box next to either Direct Deposit or U.S. Bank ReliaCard. By making this selection, you acknowledge your authorization for the Department of Social Services to credit your payments accordingly.
6. Fill out the bank information section if you chose Direct Deposit. Provide the bank name, routing number, account number, and the type of account (checking or savings). Ensure that you also attach a voided check or a bank letter confirming your account details.
7. Sign and date the form at the designated spaces. Your signature confirms the accuracy of the information you have provided and your agreement to the terms outlined.
8. Once all sections are completed, follow the instructions provided to mail, fax, or email the completed form to the appropriate address. Ensure you retain a copy for your records.
9. After submission, your card will arrive in the mail within 7-10 business days. Ensure that you monitor your mail and keep an eye out for a plain, white envelope.

Begin your application process by filling out the NEMT Payment Authorization Form online today!