Transportation, Meals, & Lodging Provider Enrollment Application

• All Out-of-state travel, meals and lodging must be prior approved by the state Medicaid office.
  
• North Dakota Medical Assistance requires all transportation providers enrolling as a provider to include a copy of a valid North Dakota driver’s license and proof of Liability Insurance with their application.
  
• North Dakota Medicaid does not allow payment to a recipient, recipient's parent, spouse, family member or household member as an enrolled provider for transportation for the recipient. Private vehicle mileage will not be allowed if there is free or low-cost transportation services available, including friends, family members or household members. This excludes providers of foster care for children.

Please complete, sign and mail all of the forms below.

All complete applications must be received with the requested drivers license and proof of liability insurance. If the department does not receive all the information, the application will be returned. This will delay the enrollment process.

1. SFN 620 Form (Non-Medical Provider Questionnaire) Rev. 06-2003
   • http://www.state.nd.us/eforms/Doc/sfn00620.pdf
2. W-9 - Both name and Tax ID Number must be exactly the way it is reported to the IRS
   • http://www.irs.gov/pub/irs-pdf/fw9.pdf
3. SFN 615 Form (Provider Agreement)
   • http://www.state.nd.us/eforms/Doc/sfn00615.pdf
4. License - current drivers license.
5. Insurance - current proof of liability insurance.

 

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