Medical Providers Forms & Resources
Submit 2015’s and 2020’s online!
Did you know NYS 2015 and 2020 forms can be submitted electronically once you’ve logged in? Processing turn-around is quicker than faxing, and you can view all your electronic forms right on your dashboard. It’s quick & easy!
- NYS 2015 Form-login to submit electronically opens a new window
- NYS 2020 Form opens a new window(login to submit electronically)
- NYS DOH Plan of Care Grid for Social and Non-Medical Transportation for the TBI Waiver and HARP BH HCBS opens a new window
- Authorization to Release Protected Medicaid Member Information to a Third Party opens a new window
- NYS Medicaid Program: Transportation Manual Policy Guidelines opens a new window
- New York Department of Health opens a new window
- New York Department of Motor Vehicles opens a new window
- Office of Temporary and Disability Assistance – Request of Fair Hearing opens a new window
- NY Connects opens a new window
- NY Medicaid Inspector General opens a new window
- Medicaid Updates Website opens a new window
Standing Order Policy (Update- August 2020): opens a new window 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-login to submit electronically opens a new window : 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 2022 opens a new window Don’t forget to login to your account to submit your 2015 electronically!
2020 (Outside Common Medical Area Form) opens a new window : 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. Don’t forget to login to your account to submit your 2020 electronically!
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 opens a new window
For guidance on completion of this form, please call the Health Department’s transportation manager, MAS, at the appropriate number for your region and county.