Current through Register No. 40, October 3, 2024
(a) All drivers shall be enrolled with the
department as:
(1) A recipient
driver;
(2) A volunteer
driver;
(3) Both a. and b.;
or
(4) A transit company
driver.
(b) All
recipient drivers shall submit to the department:
(1) A copy of a valid New Hampshire driver's
license; and
(2) A completed,
signed, and dated Form 14, "Medicaid Transportation Enrollment Form" (03/15),
attesting to the following:
"I agree to accept up to the maximum New Hampshire
Medicaid mileage allowance per trip as payment in full."
(c) All volunteer drivers shall
submit the following information to the department:
(1) A completed, signed, and dated Form 14,
"Medicaid Transportation Enrollment Form" (03/15), attesting to the following:
"I agree to accept up to the maximum New Hampshire
Medicaid mileage allowance per trip as payment in full."
(2) A copy of a valid driver's
license;
(3) Proof of automobile
liability insurance; and
(4)
Updated proof of licensure and insurance at the time each is renewed, and at
any other time when a change in status has occurred.
(d) Transit company drivers shall submit the
following information to the department:
(1)
A completed, signed, and dated Form 14b, "Medicaid Transportation Enrollment
Form - Transit Company" (03/15), certifying the following:
a. "For the purpose of establishing
eligibility to receive direct payment for transportation provided to recipients
of the New Hampshire (NH) Medicaid Program, I certify that the information
furnished in this application is true, accurate, and complete to the best of my
knowledge. I understand that, per 42 CFR 455, Subpart B, it is my
responsibility to notify the NH Medicaid Transportation office of any changes
to the information on this application, including but not limited to: name,
address, group affiliation, or change in ownership.";
b. "I understand that payment of all claims
will be from federal and state funds, and that any falsification, or
concealment of a material fact, may be prosecuted under federal and state
laws."; and
c. "I agree to accept
up to the maximum NH Medicaid mileage allowance per trip as payment in
full.";
(2) A copy of
the document received from the IRS which provided the applicant's federal tax
ID number;
(3) A completed IRS W-9
form at the time of enrollment;
(4)
A copy of the document received from the IRS which indicates the applicant's
non-profit tax-exempt status, if applicable;
(5) Proof of automobile liability insurance;
and
(6) Updated proof of insurance
at the time it is renewed, and at any other time when a change in status has
occurred.
(e) Volunteer
and transit company drivers shall submit a completed IRS form 1099 to the IRS
at the end of the calendar year if the yearly total of contracted services
exceeds $600.00.
(See Revision Note at chapter heading He-W 500); ss by
#6163, eff 1-4-96, EXPIRED: 1-4-04
