Non-Emergency, Non-Ambulance Medical Transportation Information- Fleet/ Driver Addition
INSTRUCTIONS FOR COMPLETING NEMT REQUEST FOR INSPECTION - FLEET ADDITION
The Request for Inspection-Fleet Addition Form is to be used to add vehicles to your fleet. All additions to your fleet, whether permanent or temporary, must be reported to the Department and permitted for use prior to the vehicle being used to transport Medicaid clients. Please keep copies of this form and these instructions in your files at all times. You may copy the form as needed.
Fill in all blanks on the form with the appropriate information and attach the following documents:
1. The Certificate of Registration from the Louisiana Office of Motor Vehicles
2. A copy of your current insurance certificate showing the Vehicle Identification Number of the new vehicle added to your policy. Your insurance agent must follow this up with an original Certificate of Insurance showing that the new vehicle has been added to your policy. We do not accept Louisiana Automobile Insurance Identification cards.
3. A NEMT Vehicle Inspection Form (HSS-MT-9A) with section 1 completed.
4. Louisiana Public Service Commission's Affidavit for Hire Waiver (MT-10 Affidavit)
5. Copy of the appropriate municipal license or licenses (city permit, business or occupational license that is obtained from the Sheriff’s Department Tax Division, or the municipality’s Finance Department), and if you are located in one of the following parishes:
(Note: this list of required attachments is also on the fleet addition form.)
Fax the completed form HSS-MT-15 and the 3 required attachments to the Health Standards NEMT Program Desk at 225-342-0157. All documents are to be faxed to this office at the same time. Keep the originals and give them to the surveyor during the inspection of your vehicle.
A temporary permit will be faxed to you within two working days of receipt of your vehicle information. Complete this permit, sign it, and fax it to this office at the telephone number listed above. The information will be reviewed; the permit signed, and will be faxed back to you. One you receive the permit signed by the NEMT Program Manager, you may begin to use the vehicle. A copy of the permit should remain in the vehicle at all times.
If adding a Driver the Driver Information Form should be filled out and returned to the Department.