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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....

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To schedule a ride, call MediTrans at 866-430-1101 (TTY 711). Rides must be set up 48 hours before the appointment. For details about your ride after you set it up, please call 866-430-1101 (TTY 711) and choose option 2.

If you need transportation services right away, call ModivCare at 855-397-3602. Our after-hours call center is staffed 24 hours to handle ride assistance and urgent reservation requests (including discharges) 365 days a year.

Medicaid Transportation - South Carolina offers transportation to members of Medicaid for doctors appointments, dialysis, x-rays, lab work, drug store or other medical appointments. To find out how to take advantage of this service, visit the South Carolina Department of Health and Human Services.

Medicaid is a medical assistance program that helps pay for some or all medical bills for many people who cannot afford health care such as hospital and doctor bills, prescriptions, medical equipment, rides to and from doctor visits and more.

South Carolina Medical Service Area The South Carolina Medicaid program will pay for ambulance services rendered in the SCMSA, which meet all the requirements in this manual. The SCMSA includes all of South Carolina and area(s) within 25 miles of the South Carolina Border.

Call Member Services at 866-432-0001 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Eastern time. To ask for a ride, call at least 3 days before your appointment. To cancel a ride, call at least 24 hours in advance.

Income Limits Family SizeMonthly Income (Effective 03/01/2024 ) 1 $2,610.40 2 $3,542.93 3 $4,475.46 4 $5,408.005 more rows

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232