Medicaid Transportation Exception Verification
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MEDICAID TRANSPORTATION EXCEPTION VERIFICATION
Section 1 – Identifying Information (DSS completes)
_________________________ County Department of Social Services
Date ______________
Beneficiary Name
__________________
Address
____________________________
Phone
__________________
Medicaid ID ____________________________
Caseworker Name ___________________
Caseworker Phone ______________________
Section 2 – Medicaid Beneficiary Consent to Release Information
I, ______________________________, have requested Medicaid transportation assistance.
I authorize _____________________________ to release information requested below to the
(doctor, clinic, other medical provider name)
Department of Social Services.
This authorization is valid for up to one year from the date signed. I understand that I may revoke this authorization
at any time by submitting a written request to the County DSS. I further understand that any action taken on this
authorization prior to the rescinded date is legal and binding.
__________________________________________________________
________________________
Medicaid beneficiary’s or representative’s signature
Date
Note to beneficiary: bring this form to your provider to complete and have your provider fax it
to DSS at _____________. Forms returned directly to DSS by the beneficiary will not be
considered.
Section 3 – Exception Requested and Justification
Medicaid regulations limit transportation to the closest appropriate provider by the most
economical means available. You only need to complete this form if an exception is required.
The Medicaid beneficiary named above has requested:
Transportation to a provider located outside of the county’s normal service area
A special mode of transportation (attendant, service animal, vehicle type, etc.)
Lodging
Duration of Need: From: _________________ to ________________ or Permanent ____
If the beneficiary is requesting transport to a provider located outside the county’s normal
service area: Please provide the name, address and phone number of the medical provider to
whom the beneficiary is being referred;
Name ___________________________________________
Phone _____________
Address ______________________________________________________________
Please explain why this beneficiary cannot be served by a provider within the normal county
service area.
____________________________________________________________________________
____________________________________________________________________________
Continued on next page
pg. 1 of 2
DMA‐5048 (Rev. 1/15)
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Parent category: Medical