Emedny 424601 06 16 2026

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The document is a Transportation Information Request Form that outlines the necessary information required for processing enrollment applications for out-of-state medical service providers. It includes sections for confirming participation in Medicaid services, listing ownership and corporate affiliations, detailing professional licenses, providing employment history, and specifying vehicle information. The form emphasizes the importance of submitting complete and accurate information to avoid delays in the enrollment process.

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Click ‘Get Form’ to open the emedny 424601 06 16 in the editor.
Begin by answering the first question regarding your status as an out-of-state provider. If applicable, indicate the date of service and proceed to sign on page 6 if you select 'Yes'.
Continue to the next section where you will list any other companies owned by individuals from Section 1. Fill in the company name, FEIN or Provider Number, and all owners' names.
In the following sections, provide details about professional licenses held by owners, any medical care institutions operated, and transportation service percentages.
Complete sections regarding bank information and personnel authorized to sign checks. Ensure all fields are filled accurately for a smooth submission.
Finally, review all entries for accuracy before submitting your form through our platform.

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How much does Medicaid pay for transportation in NY?

How do I contact MTM if I have a service issue or complaint? 5. What if my ride is late? If your ride is more than 15 minutes late, call MTM at 1-855-330-9131.