Individual Transportation Participant Agreement Form
The Individual Transportation Participant (ITP) Agreement is required for participants in the Individual Transportation Program. The document includes instructions, required forms, and important information on how to schedule and receive payment for transportation services provided. It needs to be filled out, signed, and returned along with necessary documents.
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How do I fill this out?
To fill out this form, review each section carefully and provide the required information. Make sure to answer all questions accurately and attach the necessary documents. Sign and date the Agreement before returning it.
How to fill out the Individual Transportation Participant Agreement Form?
1
Review each section carefully and provide the required information.
2
Answer all questions accurately.
3
Attach the necessary documents.
4
Sign and date the Agreement.
5
Return the completed form.
Who needs the Individual Transportation Participant Agreement Form?
1
Medicaid members who require transportation services to and from medical appointments.
2
Individuals who have been approved as an Individual Transportation Participant (ITP).
3
Healthcare providers who need to log and approve transportation services.
4
Family members who transport Medicaid members to covered appointments.
5
Participants in the Individual Transportation Program (ITP) seeking mileage reimbursement.
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What are the instructions for submitting this form?
Submit the completed ITP Agreement Form along with required documents to Access2Care by mail, fax, or email. Fax number: 713-747-9453, Mailing address: A2C ITP Claims, 9555 W Sam Houston Pkwy S, Suite 500, Houston, TX 77099. Email: claimsdept@gmr.net. Ensure all details are accurate, and attached documents are complete. For any questions, contact Access2Care at 844-688-7462.
What are the important dates for this form in 2024 and 2025?
Submit the ITP Agreement Form and trip logs within 95 days of the ride date.
What is the purpose of this form?
The Individual Transportation Participant (ITP) Agreement Form is essential for Medicaid members and approved ITPs to gain access to transportation services and mileage reimbursement. The form ensures that all necessary details and documents are collected to validate the transportation services provided. By completing and submitting this form, participants and drivers can receive payments for services rendered and ensure compliance with Medicaid requirements.
Tell me about this form and its components and fields line-by-line.
- 1. Driver's License: Photocopy of a valid driver's license.
- 2. Vehicle Insurance: Proof of current vehicle insurance covering the vehicle used for transportation.
- 3. Social Security Card: Photocopy of the driver's Social Security Card.
- 4. Vehicle Registration: Proof of valid vehicle registration.
- 5. Vehicle Inspection Report: A valid Vehicle Inspection Report (VIR).
- 6. Trip Log: Log signed and stamped/dated by a healthcare provider for each trip.
What happens if I fail to submit this form?
Failure to submit this form may result in the inability to receive reimbursement for transportation services or schedule future trips.
- No Reimbursement: You will not be reimbursed for trips made without submitting the required form and documents.
- Inability to Schedule Trips: Future trip scheduling with Access2Care will not be possible.
How do I know when to use this form?
- 1. Medicaid Transportation: Use this form for transportation to and from Medicaid-covered appointments.
- 2. ITP Participant Requirement: If you are an approved ITP, use this form to log and validate your trips.
- 3. Reimbursement Requests: Submit for mileage reimbursement for eligible trips.
Frequently Asked Questions
How can I fill out the ITP Agreement Form?
Use our PDF editor to enter your information, answer questions, and attach required documents. Sign and date the form before submitting it.
How do I sign the ITP Agreement Form?
Use the built-in signature tool on PrintFriendly to add your digital signature. Save and download the signed form.
Can I share the ITP Agreement Form online?
Yes, generate a shareable link on PrintFriendly or download and attach the document to your communications.
What information do I need to provide in the form?
Provide your personal information, driver's license details, vehicle insurance, registration, and other required documents.
How do I schedule trips with Access2Care?
Call the assigned numbers listed in the form to schedule trips in advance. Obtain a confirmation number for each trip.
What happens if I don’t submit the ITP Agreement Form?
You will not be able to receive reimbursement for transportation services or schedule future trips with Access2Care.
How can I edit the ITP Agreement Form?
Use the PDF editor on PrintFriendly to make any necessary changes and save the edited version.
Is there a deadline for submitting the ITP Agreement Form?
Yes, the form and trip logs should be submitted as soon as possible, preferably within 95 days from the date of the ride.
What types of trips are covered for reimbursement?
Trips to and from Medicaid-covered services that are scheduled in advance with Access2Care are eligible for reimbursement.
Can I track the status of my reimbursement request?
Yes, you can contact Access2Care for any questions regarding the status of your reimbursement request.
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