Resources and forms collected in one place.
Standing Order Renewal Policy: Standing orders are set up on a bi-annual basis, set to expire at the end of June and December. Standing orders scheduled at any time between December and May, will expire in June. Those placed June through November, will expire in December. Please Note: Standing orders do not auto-renew; rather either the medical practitioner or enrollee will need to renew by June 15, or December 15.
2015 (Verification of Transportation Abilities) Form: An enrollee’s transportation ability registered within the MAS system by this form. This form is filled out by the enrollee’s relevant medical practitioner and indicates what mode of transportation the enrollee is capable of using on a day to day basis.
2020 Form (Outside Common Medical Area Form): The information on this form helps in establishing an enrollee’s need for transportation outside their common medical market. This occurs when necessary care is receivable only outside the community generally. Transportation may be authorized for a Medicaid enrollee when the appropriate Medicaid-covered treatment is unavailable locally per NYCRR Title 18 §505.10, §360, 92 ADM 21, and/or review by representatives of the NYS Department of Health and/or its agents. Please note: While this completed form is required, completion of this form does not guarantee authorization of Medicaid-funded transportation outside the common medical marketing area. The Medicaid program will not authorize transportation outside the common medical marketing area when the enrollee has been non-compliant with local medical providers and that enrollee is unable to receive services locally based on their own actions. For guidance on completion of this form, please call the Health Department’s transportation manager, MAS, at the appropriate number for your borough or county.
MAS Individual Trip Request Form and Transportation Request Spreadsheet – both forms can be faxed to MAS, at (315) 299-2786. The Transportation Request Form can be filled out to request a single trip. Use the Transportation Request Spreadsheet for multiple rides
Physician Attestation for Mileage Reimbursement Individual Appointments
Bus Pass Adminstrator Form
Enrollee Daily Appointment Bus Pass Reimbursement
Multiple Appointment Bus Pass Reimbursement
Individual Appointment Mileage Reimbursement
Multiple Appointment Mileage Reimbursement
Mileage Reimbursement Guide 12.2017
Enrollee Consent to Release Information