Get Dhhr Form Dfa Nemt 1

Filling out the Dhhr Form Dfa Nemt 1 online is a critical step in requesting transportation assistance for medical appointments. This guide is designed to help you navigate each section of the form with ease, ensuring that all required information is accurately provided.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by filling in Section I: To be completed by applicant. Provide your name, the dates of travel, and your contact details, including street address, city, zip code, telephone number, county, social security number, and Medicaid ID number for each patient as indicated. Make sure all information is accurate.
3. In Section II: Applicant responsibilities and signature, carefully read each statement. For each statement, mark ‘Yes’ or ‘No’ to indicate your understanding of the responsibilities outlined. These responsibilities include the necessity of submitting the application within a specified timeframe and understanding the implications of providing false information.
4. You must read through all statements, particularly those regarding approval requirements for travel expenses and available transportation options. Confirm your understanding by checking Yes or No.
5. Once you have completed the acknowledgments in Section II, sign and date the form to certify that you have understood and provided true and correct information.
6. Proceed to Section III: Verification of travel and attendance. This section requires signatures from both your medical provider and the transportation provider. Fill in the patient's information and the purpose of the visit.
7. Complete the necessary details for your medical provider, including the date and time of the appointment. Ensure the medical provider or authorized representative signs and dates this section.
8. In the transportation provider section, indicate the type of transportation used and provide the driver's name and signature along with costs incurred for mileage, parking, and other expenses, where applicable.
9. Ensure all supporting documents, such as receipts for lodging and transportation fares, are attached before submission.
10. Review the entire form for accuracy and completeness. Once satisfied, you can save changes, download, print, or share the completed form according to your preference.

Start completing your Dhhr Form Dfa Nemt 1 online today to ensure you get the assistance you need.