Downloads

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Title	Description
Covered & Non Covered Services	New York Department of Health Medicaid Covered & Non-Covered Services	Download
DOH Intro letter to Medical Providers	Introduction letter for LogistiCare’s management of Non-Emergency Medicaid Transportation	Download
Facility Services Web Portal Admin User Form	Request Form to Setup an Administrator Account for Requesting Transportation Online	Download
Form 2015, Medical Justification (Adobe PDF format)	Medicaid Transportation Justification Request Form. There is no trip information on this form.	Download
Form 2015, Medical Justification (Microsoft Word format)	Medicaid Transportation Justification Request Form. There is no trip information on this form.	Download
Webinar for Medical Practitioners	Presentation to medical practitioners to introduce LogistiCare	Download
Standing Order Request Form with Treatment Types DOH approved 07-13-12.	To request NEMT for fee for service enrollees needing regularly reoccurring transport one or more times per week for one or more months duration to a Medicaid covered service. Has 2015 attestation, and space to name the transportation provider.	Download
What LogistiCare is responsible for in Bronx, Brooklyn, Queens, Manhattan and Staten Island.	Key terms, phone numbers, and explanations for services provided by LGTC in Bronx, Brooklyn, Queens, Manhattan and Staten Island.	Download
Ordering Guidelines Manual	New York City Transportation Guidelines for Medical Practitioners.	Download
Medicaid Transportation Request Fax Form With 2015 Attestation (called "Transportation Request Fax Form (3/2012)")	LogistiCare Transportation Request fax form, for multiple trips, with the 2015 attestation (called "Transportation Request Fax Form (3/2012)"). Gives space for naming the transportation provider.	Download
Medicaid Transportation Request Fax Form Without 2015 Attestation (called "Transportation Request Fax Form W/O Attached Verification (4/2012)")	LogistiCare Transportation Request fax form, for multiple trips, without the 2015 attestation. This includes a cover page to be used as part of the fax, and it names the transportation provider. Form 2015 has already been submitted, or will be submitted.	Download
Referral to Another Medical Site Transportation Request Fax Form	Medical transportation request fax form to use when referring an enrollee to another medical practitioner.	Download
NY State Requirements for the Quality of Transportation Services.	Requirements for participation as a Medicaid Transportation Provider.	Download

Fillable Forms

The forms listed below are versions of the same forms above but distributed as Adobe PDF fillable forms. The information fields such as names, phone numbers, and dates may be filled out on your computer rather than by hand. This is often easier to use and when printed are easier to read.

Title	Description
Referral to Another Medical Site Transportation Request Fax Form	Medical transportation request fax form to use when referring an enrollee to another medical practitioner.	Download
Standing Order Request Form with Treatment Types DOH approved 07-13-12.	To request NEMT for fee for service enrollees needing regularly reoccurring transport one or more times per week for one or more months duration to a Medicaid covered service. Has 2015 attestation, and space to name the transportation provider.	Download
Medicaid Transportation Request Fax Form Without 2015 Attestation (called "Transportation Request Fax Form W/O Attached Verification (4/2012)")	LogistiCare Transportation Request fax form, for multiple trips, without the 2015 attestation. This includes a cover page to be used as part of the fax, and it names the transportation provider. Form 2015 has already been submitted, or will be submitted.	Download
Form 2015, Medical Justification	Medicaid Transportation Justification Request Form. There is no trip information on this form.	Download
Medicaid Transportation Request Fax Form With 2015 Attestation (called "Transportation Request Fax Form (3/2012)")	LogistiCare Transportation Request fax form, for multiple trips, with the 2015 attestation (called "Transportation Request Fax Form (3/2012)"). Gives space for naming the transportation provider.	Download

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