Resources and forms collected in one place.
Medicaid Transportation Ordering Guidelines General: NYS DOH general guidelines for scheduling Non-Emergency Medicaid Transportation through MAS.
Standing Order Policy (Update- August 2020): Standing orders are reoccurring appointments to the same location, at the same times of day, same days of the week, for the same medical reason, and can be scheduled for up to 6 months. Standing orders do not automatically renew upon expiration; rather, the medical practitioner will extend a standing order at any time to ensure transportation continues uninterrupted. UPDATE: As of October 1st, 2020, standing order requests will no longer be accepted by enrollees and can only be scheduled by the enrollee’s medical provider online using MAS System 2.0. If you do not yet have access to MAS System 2.0, reach out to your Field Liaison for assistance. Their contact information can be found by clicking “Locations”. Select your county for a list of key contacts.
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. DOH 2015 Policy and Procedure updated 2018
2020 (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. CMA Policy Updated 2018
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
NYS DOH Plan of Care Grid for Social and NEMT for the TBI Waiver, CFCO, and HARP BH HCBS
Enrollee Consent to Release Information