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  • West Virginia Application For Non Emergency Medical Transportation Program Nemt

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Ink and turned in to the local DHHR office within 60 days of the earliest trip. Name: Date(s) of Travel: Street, Route or PO Box Number: City Zip Code Telephone Number County Social Security Number MA ID number from each patient s Medicaid card (this is the 11-digit number to the left of the person s name on the card): Section II: APPLICANT RESPONSIBILITIES AND SIGNATURE Please read each statement carefully and check either Yes or No. 1. Yes No I understand that I may request a.

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For Office Use Only New York State Department Of Taxation And Finance IT-203-S , 2001, And Ending Form IT-203-S-ATT: 2001, Attachment To Form IT-203-S, IT203SATT - Tax Ny New York State Department Of Taxation And Finance For Office Use Only Group Return For Nonresident For Office Use Only New York State Department Of Taxation And Finance Amended Nonresident And

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Intake Process: Make a reservation on the website or call the NEMT reservation line at 1-866-386-8331 at least five business days prior to the scheduled medical appointment.

Modivcare has partnered with Corporate Cost Control (CCC) for employment verification services. Please visit .CCCVerify.com or call (855) 901-3099 to instantly obtain employment verification reports and letters.

Call the Modivcare reservations line at 866-386-8331 at least seven (7) days before the scheduled medical appointment.

Members with Medicaid may be eligible for transportation services. Use the options below to schedule Non-Emergency Medicaid Transportation. Reservations Line - Call toll-free: (844) 549-8353. Reservations are taken Monday through Friday between the hours of 7:00 am and 6:00 pm.

What documents do I need to become a provider? Current business license. Verification of liability insurance coverage. Driver credentials. Current Criminal background checks for all drivers. Current drug screens for all owners and drivers. Current motor vehicle driving report for all drivers.

On January 6, 2021, LogistiCare changed its name to ModivCareTM.

​ 24-hour federal call center helpline – 1-800-318-2596 or TTY 1-855-4325.

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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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