Medicaid Transportation Exception Verification Page 2

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Section 3 – Exception Requested and Justification
If the beneficiary is requesting a special mode of transportation or has a special need, please
explain:
Indicate the special mode or need? (
) ________________
attendant, service animal, vehicle type, other
Why is this accommodation necessary?
____________________________________________________________________________
____________________________________________________________________________
If the beneficiary will need lodging during his/her treatment, please explain why the beneficiary
will have to stay overnight near the treatment facility (to be completed by provider at facility).
____________________________________________________________________________
____________________________________________________________________________
For how long (number of nights) will the beneficiary need to remain near the facility?
From ______________ To ______________
Section 4 -- Attestation
To the best of my knowledge, the above statements are true and correct.
Name of provider completing form (print): ______________________
Phone __________
Provider’s Signature: _________________________________
Date _________________
***Incomplete or inaccurate forms will not be approved, and could delay transportation to
medical services***
pg. 2 of 2 
DMA‐5048 (Rev. 1/15)

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