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Date Name of Medicaid provider/facility Name of individual completing form please print Phone number of person completing form Signature of person completing form DMA-5118A New 1-15. Print Form MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED SERVICE TO Medicaid Enrolled Provider From County Department of Social Services 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* 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. Print Form MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED SERVICE TO Medicaid Enrolled Provider From County Department of Social Services 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* 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. G*S* 108A-25 and rules adopted by the State of North Carolina* 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. Print Form MEDICAID TRANSPORTATION VERIFICATION OF RECEIPT OF MEDICAID COVERED SERVICE TO Medicaid Enrolled Provider From County Department of Social Services 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* 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.

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Keywords relevant to Dma 5118

  • medicaid
  • completing
  • verification
  • enrolled
  • audit
  • recipient
  • provider
  • administer
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