Get Nh Sr 99-46 2012-2026

Completing the NH SR 99-46 Medicaid Transportation Reimbursement Form online can help ensure that you receive the reimbursement you deserve for transportation services. This guide provides clear and supportive instructions to help you through the process of filling out the form accurately.

Follow the steps to fill out the NH SR 99-46 online with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide your payee information. Enter the Key Name and Resource Number you received upon enrollment. If you do not have this information, contact the Medicaid Transportation Coordinator for assistance.
3. Enter the Recipient Information. Print the first three letters of the first and last names and include the Medicaid ID number from the recipient's Medicaid card.
4. Complete the Trip Information section. Choose whether the payee is the self or a volunteer transporter, and provide the from and to locations, ensuring to enter only the first eight letters of the town or city along with the zip code.
5. List the Medicaid Provider Name and the address where services were rendered, following the suggested format of last name, first name.
6. Obtain the medical provider's signature and date on the form at the time of service.
7. Submit the form to Medicaid Transportation within 90 days of service by sending the white copy to the specified address. Retain the yellow copy for your records.

Begin the process now and complete your NH SR 99-46 form online!