HomeMy WebLinkAboutExhibit 2Attachment A
Medicaid Waiver Services Agreement
EXAMPLE
Agency for Persons with Disabilities
Transportation Data Collection Tool
•
APD Area Office:
Name of Provider:
Medicaid Provider Number:
Reporting Period: January 1, 200_ through March 31, 200_
Complete for each billing category as
appropriate to approved billing
methodology.
A. Month
Total # of one-way trips
Total # of vehicle miles for all one-way trips
Average # of consumers sharing a vehicle
Total cost of operation during reporting
period
B. Trip
Total # of one-way trips
Total # of vehicle miles for all one-way trips
-Average # of consumers sharing a vehicle
Total cost of operation during reporting
period •
C. Mitt_
Total '# .of one-way trips
Total # of vehicle miles for all one-way trips
Average # of consumers sharing a vehicle
Total cost of operation during reporting
period
GRAND TOTAL (All billing Categories).
Total r� of one-way trips
Total #'of vehicle miles for all one-way trips
Average* of consumers sharing a vehicle
Total cost of operation during reporting
period
Wheelchair Accessible
Vehicle
Signature of Provider :
Title of Provider: Telephone #:
Non Wheelchair Accessible Vehicle
Date of S *nature:
Page of
Total