New York Facility Network

New YorkFacility Network

Downloads

Please click on the title that corresponds to the document you would like to view, and then click on print or download as necessary.

 TitleDescription
Nassau Suffolk DOH - List of Medicaid Covered ServicesList of Medicaid Covered Services in Nassau and Suffolk Counties.
Nassau Suffolk DOH - Standing Order Request Form with Treatment TypesTo request NEMT for fee for service enrollees needing regularly reoccurring transport one or more times per week for one or more months duration to a Medicaid covered service. Has 2015 attestation, and space to name the transportation provider.
Nassau Suffolk DOH - Social Transportation Guidance for the Traumatic Brain Injury (TBI) Waiver ProgramGuidelines for Approving Requests for Social Transportation of Persons Enrolled in the Traumatic Brain Injury (TBI) Waiver Program.
Nassau Suffolk DOH - Quick Reference sheet for facilitiesFacility handouts for enrollees in 4 languages‎.
Nassau Suffolk DOH - Outside Common Medical Market Area FormNYDOH form necessary to approve trip requests Outside the Nassau and Suffolk Counties Common Medical Market Area.
Nassau Suffolk DOH - NYS DOH Care Plan Grid for Transportation of TBI Waiver ParticipantsCare Plan Grid required by NYS DOH to be submitted for Transportation of TBI Waiver Participants.
Nassau Suffolk DOH - Medicaid Transportation Request Fax Form With 2015 AttestationLogistiCare Transportation Request fax form, for multiple trips, with the 2015 attestation. Gives space for naming the transportation provider.
Nassau Suffolk DOH - Long Island MCO Carve Out informationList of Medicaid Managed Care Plans affected by the 12/1/2015 Long Island transportation carve-out.
Nassau Suffolk DOH - LogistiCare Hospital Discharge ChecklistInformation needed by LogistiCare when calling to schedule a discharge.
Nassau Suffolk DOH -Medical Facility Web Portal Admin User FormRequest Form to Setup an Administrator Account for Requesting Transportation Online through TripCare.
Nassau Suffolk DOH - Introduction Letter Letter from NYDOH announcing non-emergency transportation services for Medicaid FFS enrollees will be coordinated by LogistiCare effective July 1, 2015.
Nassau Suffolk DOH - Form 2015 - Medical JustificationMedicaid Transportation Justification Request Form. There is no trip information on this form.
Gas ReimbursementExplains the criteria and how plan members are reimbursed.
Gas Reimbursement FormA form, which must be completed by a medical professional, when requesting transportation for a member that has access to a vehicle or can be transported by friend or relative.
Mass Transit Department, MetroCard Request FormA form used for a Mass Transit request.
Mass Transit Department, MetroCard Hospital-Facility Reimbursement Form A member reimbursement form which is utilized by Hospitals, Facilities, and programs who distribute MetroCards for reimbursement.
MLTC - Single Trip Reservation FormA form used to request a single trip for a plan member.
Form W-9, Request for Taxpayer Identification Number and CertificationIRS Form W-9 is used by a person who files information returns with the IRS to report transactions.
Standing Order Request FormA form used to request recurring transportation for a member that goes to the same facility three or more times per week.
Single Trip FormA form used to request a single trip for a plan member.
Physician’s Transportation Restriction FormA form, which must be completed by a medical professional, when requesting transportation for a member that is not able to utilize public transportation.
AmeriChoice Announcement to FacilitiesInforms AmeriChoice providers that effective November 1, all non-emergency transportation services for members with transportation benefits must be pre-arranged through LogistiCare.
AmeriChoice Announcement to Transportation ProvidersInforms AmeriChoice transportation providers that effective November 1, LogistiCare will be arranging and providing all transportation for AmeriChoice members.
WellCare of New York, Inc. Announcement to FacilitiesInforms WellCare of New York Health Plan providers that effective December 1, 2010, non-emergency transportation services will be coordinated by LogistiCare.
Affinity Announcement to FacilitiesInforms Affinity Health Plan providers that effective November 1, all non-emergency transportation services for Medicaid, Medicare Advantage, and Medicaid Advantage members with transportation benefits must be pre-arranged through LogistiCare.
Amerigroup Announcement to FacilitiesInforms Amerigroup Health Plan of New York providers that effective November 1, all non-emergency transportation services for Medicaid, Medicare and MLTC members with transportation benefits must be pre-arranged through LogistiCare.

Click the button below to download a free PDF reader if no PDF reader is currently installed.

Download Adobe Acrobat Reader