Member Downloads

Please click on the Download link that corresponds to the document you would like to view, and then click on Open or Save when prompted.

 TitleDescription 
Member Handbook for Riding NEMTA Medicaid Member’s Non-Emergency Medicaid Transportation(NEMT) guide.Download
FFS and Managed Care Transportation Telephone NumbersList of VA FFS Medicaid and MCO Transportation FFS contact telephone numbers.Download
Tips for Arranging Medicaid Non-Emergency TransportationProvides Tips for members on how to arrange Medicaid Non-Emergency Transportation.Download
LogistiCare 5 Day Notice Requirement FlyerInforms members a 5 day notice is required to schedule non-emergency transportation.Download
Medical Necessity FormMust be completed by a medical professional or qualified case manager. This form may be required if a level of service is questionable when requesting transportation for a member that is not able to walk.Download
Compliment and Complaint FormA form used to report issues or dissatisfaction with LogistiCare or transportation services.Download
Mileage Reimbursement InstructionsExplains the criteria and how the members are reimbursed.Download
Mileage Reimbursement FormA form, which must be completed by a medical professional, when requesting transportation for a member that has access to a vehicle or can be transported by a friend or relative.Download
Volunteer Driver FlyerInforms who volunteer drivers are and lists the requirement of becoming a volunteer driver.Download
Attendant Care Eligibility Assessment FormAn eleven question assessment that provides descriptive information regarding a member’s behavior during transport. This assessment is used in the attendant approval/denial process.Download
Consent and Release of Liability Form for Transporting Minor Children to after school and day support programs.Must be completed by a parent or legal guardian when requesting transportation for minor children under the age of 18. This form must be completed and returned to LogistiCare’s Utilization Review Department prior to the transport date.Download
Virginia Medicaid/FAMIS Appeal FormA form the member uses to explain reasons for an appeal.Download

©2014 Virginia Department of Medical Assistance Services, All rights reserved.       Web Policy