Form - Dfa-Nemt-1a - Supplement To Application For Nemt Reimbursement Program
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2WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES
SUPPLEMENT TO APPLICATION FOR NEMT REIMBURSEMENT PROGRAM
This supplemental sheet is used with the DFA-NEMT-1 and contains space for 3 additional trips for a total of 4
per application. Application must be received by DHHR within 60 days of the date of the first trip.
IMPORTANT: Payment will be made to the person or company named on each verification form. If you
provide your own transportation, you must enter your own name and address in this section as the Driver. If
the wrong name and/or address is entered, duplicate payment will not be made.
Payment cannot be
processed unless the Driver’s SSN or tax ID number is entered.
Mileage is reimbursed at the current state mileage reimbursement rate for the shortest round-trip route from
the patient’s home to the medical facility or physician’s office. Lodging must be pre-approved for the most
economical rate and must be verified as necessary due to the length of travel, time of appointment, and/or
length of treatment. Meals are reimbursed only when lodging has been approved. Additional reimbursement
may be made for tolls and parking, as appropriate.
VERIFICATION OF TRAVEL AND ATTENDANCE FOR NEMT
For DHHR Use Only:
MA ID ____________________________
Medical Provider: Do not sign if the medical service/treatment
Driver’s VN
_______________________________
is not billable or billed to the Medicaid Program.
Patient’s Name
___________________________________________________
SSN ___________________________
Initial
Purpose of Visit:
Routine
Follow-up
Walk-in
Name and Address of Medical Provider
_____________________________________________________________________
Date of Appointment ______________________________________________
Time of Appointment ___________________
________________________________________________________________________________
_________________
Signature of Medical Provider or Authorized Representative
Date
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Transportation Provider:
Private Vehicle
Taxi
Bus
Plane
Community Van
Other
___________________________________________________________________
____________________________
Driver’s/Carrier’s Name (Please print)
SSN or Tax ID
Driver’s Signature ____________________________________________________
Date ______________________
Mailing address__________________________________________________________
Phone _____________________
Private Vehicle Cost: Mileage________ Parking _________Tolls _________
Common/contract Carrier: Round-trip fare __________________
For DHHR Use Only:
Lodging: Cost per night _________ Number of nights_________
Miles ______X______=________
Meals: Number of persons_________ Number of meals per person_________
Total lodging ________________
Other costs _________________
Total for this trip _____________
(Receipts must be attached for lodging, parking and common carrier fare.)
The back of this sheet provides space for 2 additional trips. This form must be attached to the DFA-NEMT-1
(NEMT application form) if you are requesting reimbursement for more than one trip.
DFA-NEMT-1a
Rev. 6/09
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