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WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES APPLICATION FOR NON-EMERGENCY MEDICAL TRANSPORTATION PROGRAM (NEXT) Section I: TO BE COMPLETED BY APPLICANT. Note: This must be completed in
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Instructions for filling out DHHR Form DFA NEMT:

01
Start by downloading DHHR Form DFA NEMT from the official website or obtaining a hard copy from your local Department of Health and Human Resources (DHHR) office.
02
Begin by providing your personal information, including your name, address, date of birth, and contact information.
03
Next, indicate your Medicaid ID number or any other identification number required by the DHHR.
04
Specify the date and time of the appointment or medical service for which transportation is needed.
05
Indicate the type of medical service required, whether it is a routine check-up, a specialist consultation, or a medical procedure, among others.
06
Provide the name and contact information of the healthcare provider or facility where the medical service is being rendered.
07
If applicable, provide the necessary details regarding any companion or additional passengers who will be accompanying you during the transportation.
08
State your preferred mode of transportation, such as non-emergency medical transportation (NEMT), public transport, or ambulette, depending on your specific needs and eligibility.
09
Describe any special accommodations or equipment you may require during the transportation, such as a wheelchair-accessible vehicle or oxygen supply.
10
Lastly, sign and date the form to confirm the accuracy and completeness of the provided information.

Who needs DHHR Form DFA NEMT?

DHHR Form DFA NEMT is primarily needed by individuals who are enrolled in the Medicaid program and require non-emergency medical transportation for their healthcare needs. This form ensures that the DHHR has the necessary information to coordinate and arrange transportation services to and from medical appointments or other healthcare-related services. Individuals who have mobility limitations, lack reliable transportation options, or have medical conditions that prevent them from using regular transportation modes may utilize this form to request assistance from the DHHR in accessing the necessary medical care. It is important to consult with your healthcare provider or the DHHR office to determine your eligibility and specific requirements for using DHHR Form DFA NEMT.
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DHHR Form DFA NEMT is a form used for reporting non-emergency medical transportation services provided by the Department of Health and Human Resources.
Providers of non-emergency medical transportation services are required to file DHHR Form DFA NEMT.
DHHR Form DFA NEMT can be filled out electronically or manually with all required information about the services provided.
The purpose of DHHR Form DFA NEMT is to track and report non-emergency medical transportation services for accountability and monitoring purposes.
Information such as the date of service, type of service provided, recipient information, and provider details must be reported on DHHR Form DFA NEMT.
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dhhr form dfa nemt 1 VIRGINIA DHHR NEMT SSN WV DFA-NEMT-1 DFA-NEMT-1a 11-digit reimbursable ofstate VN III billable initialed

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