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| Nassau Suffolk DOH - List of Medicaid Covered Services | List of Medicaid Covered Services in Nassau and Suffolk Counties. |
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| Nassau Suffolk DOH - Standing Order Request Form with Treatment Types | To 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. |
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| Nassau Suffolk DOH - Social Transportation Guidance for the Traumatic Brain Injury (TBI) Waiver Program | Guidelines for Approving Requests for Social Transportation of Persons Enrolled in the Traumatic Brain Injury (TBI) Waiver Program. |
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| Nassau Suffolk DOH - Quick Reference sheet for facilities | Facility handouts for enrollees in 4 languages‎. |
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| Nassau Suffolk DOH - Outside Common Medical Market Area Form | NYDOH form necessary to approve trip requests Outside the Nassau and Suffolk Counties Common Medical Market Area. |
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| Nassau Suffolk DOH - NYS DOH Care Plan Grid for Transportation of TBI Waiver Participants | Care Plan Grid required by NYS DOH to be submitted for Transportation of TBI Waiver Participants. |
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| Nassau Suffolk DOH - Medicaid Transportation Request Fax Form With 2015 Attestation | LogistiCare Transportation Request fax form, for multiple trips, with the 2015 attestation. Gives space for naming the transportation provider. |
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| Nassau Suffolk DOH - Long Island MCO Carve Out information | List of Medicaid Managed Care Plans affected by the 12/1/2015 Long Island transportation carve-out. |
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| Nassau Suffolk DOH - LogistiCare Hospital Discharge Checklist | Information needed by LogistiCare when calling to schedule a discharge. |
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| Nassau Suffolk DOH -Medical Facility Web Portal Admin User Form | Request Form to Setup an Administrator Account for Requesting Transportation Online through TripCare. |
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| 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. |
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| Nassau Suffolk DOH - Form 2015 - Medical Justification | Medicaid Transportation Justification Request Form. There is no trip information on this form. |
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| Gas Reimbursement | Explains the criteria and how plan members are reimbursed. |
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| Gas Reimbursement Form | A 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. |
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| Mass Transit Department, MetroCard Request Form | A form used for a Mass Transit request. |
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| 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. |
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| MLTC - Single Trip Reservation Form | A form used to request a single trip for a plan member. |
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| Form W-9, Request for Taxpayer Identification Number and Certification | IRS Form W-9 is used by a person who files information returns with the IRS to report transactions. |
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| Standing Order Request Form | A form used to request recurring transportation for a member that goes to the same facility three or more times per week. |
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| Single Trip Form | A form used to request a single trip for a plan member. |
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| Physician’s Transportation Restriction Form | A form, which must be completed by a medical professional, when requesting transportation for a member that is not able to utilize public transportation. |
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| AmeriChoice Announcement to Facilities | Informs AmeriChoice providers that effective November 1, all non-emergency transportation services for members with transportation benefits must be pre-arranged through LogistiCare. |
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| AmeriChoice Announcement to Transportation Providers | Informs AmeriChoice transportation providers that effective November 1, LogistiCare will be arranging and providing all transportation for AmeriChoice members. |
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| WellCare of New York, Inc. Announcement to Facilities | Informs WellCare of New York Health Plan providers that effective December 1, 2010, non-emergency transportation services will be coordinated by LogistiCare. |
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| Affinity Announcement to Facilities | Informs 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. |
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| Amerigroup Announcement to Facilities | Informs 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. |