New York MedicaidTransportation Justification Request Medical Justification for Transport Mode Form

The physician (or the entity making the request) understand that orders for Medicaid-funded travel may result from the completion of this form. They (or the entity making the request) understand and agree to be subject to and bound by all rules, regulations, policies, standards and procedures of the New York State Department of Health which requires providers to pay restitution for any direct or indirect monetary damage to the program resulting from improperly or inappropriately ordering services. The New York Medicaid Transportation Justification Request Medical Justification for Transport Mode Form 2015 mobile app allows you to replace your paper record with a smartphone, tablet or desktop. The mobile form includes fields to document items such as patient name, date of birth, Medicaid number, physician's name and captures physician's signature. Once the mobile app is filled out a secure PDF is generated. The PDF is easy to share, and a copy is stored in your account for your transportation and receiving records. You can also use the App Builder to personalize and customize this mobile form.