Section He-W 574.03 - Driver Participation(a) All drivers shall be enrolled with the department as:(4) A transit company driver.(b) All recipient drivers shall submit to the department: (1) A copy of a valid New Hampshire driver's license; and(2) A completed, signed, and dated Form 14, "Medicaid Transportation Enrollment Form" (03/15), attesting to the following: "I agree to accept up to the maximum New Hampshire Medicaid mileage allowance per trip as payment in full."
(c) All volunteer drivers shall submit the following information to the department: (1) A completed, signed, and dated Form 14, "Medicaid Transportation Enrollment Form" (03/15), attesting to the following: "I agree to accept up to the maximum New Hampshire Medicaid mileage allowance per trip as payment in full."
(2) A copy of a valid driver's license;(3) Proof of automobile liability insurance; and(4) Updated proof of licensure and insurance at the time each is renewed, and at any other time when a change in status has occurred.(d) Transit company drivers shall submit the following information to the department: (1) A completed, signed, and dated Form 14b, "Medicaid Transportation Enrollment Form - Transit Company" (03/15), certifying the following: a. "For the purpose of establishing eligibility to receive direct payment for transportation provided to recipients of the New Hampshire (NH) Medicaid Program, I certify that the information furnished in this application is true, accurate, and complete to the best of my knowledge. I understand that, per 42 CFR 455, Subpart B, it is my responsibility to notify the NH Medicaid Transportation office of any changes to the information on this application, including but not limited to: name, address, group affiliation, or change in ownership.";b. "I understand that payment of all claims will be from federal and state funds, and that any falsification, or concealment of a material fact, may be prosecuted under federal and state laws."; andc. "I agree to accept up to the maximum NH Medicaid mileage allowance per trip as payment in full.";(2) A copy of the document received from the IRS which provided the applicant's federal tax ID number;(3) A completed IRS W-9 form at the time of enrollment;(4) A copy of the document received from the IRS which indicates the applicant's non-profit tax-exempt status, if applicable;(5) Proof of automobile liability insurance; and(6) Updated proof of insurance at the time it is renewed, and at any other time when a change in status has occurred.(e) Volunteer and transit company drivers shall submit a completed IRS form 1099 to the IRS at the end of the calendar year if the yearly total of contracted services exceeds $600.00.N.H. Admin. Code § He-W 574.03
(See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04
New. #8732, eff 9-30-06
Amended byVolume XXXV Number 18, Filed May 7, 2015 , Proposed by #10810, Effective 4/9/2015, Expires4/9/2025.