January 13, 2017 Welcome to Project Amistad! Thank you for requesting an enrollment packet to become an Individual Transportation Participant (ITP). We feel honored that you have chosen us to fulfill your medical transportation needs and we are eager to be of service. Our friendly and knowledgeable agents are standing by to answer your questions and to assist you in setting up your non-emergency medical transportation trips. Feel free to contact us with any questions or concerns at 1-877-633-8747 between the hours of 7:00 am and 5:00 pm Mountain time. Below are a few things you will find within our ITP packet of enrollment: Welcome Letter Individual Transportation Participant Checklist o Provides you with information of what is needed to consider your ITP application complete Your ITP application o ITP Self, complete and submit pages 2 6 o ITP Other, complete and submit pages 2 7 ITP Service Record/Claim form o A Service Record must be signed by a physician, signed by the ITP driver, and submitted to Project Amistad within 95 days from the scheduled trip. o Project Amistad cannot process reimbursement if this form is not complete and submitted. Please note the following: You may begin scheduling trips once you receive a letter from Project Amistad letting you know that your enrollment packet has been received, reviewed, and approved. Once this letter is received, you can begin calling 1-877-633-8747 to schedule your trips. If you do not wish to use Electronic Funds Transfer for your reimbursement, an ADP card can be issued to you. The ADP card is like a debit card that can be used anywhere VISA is accepted. Please be sure to select ADP on page 5 and complete sections 1 and 3. No pictures will be accepted. Remember to fill out everything completely and to return your ITP application along with copies of the following: 1. Driver s License 2. Current Vehicle Registration 3. Social Security Card 4. Current Vehicle Insurance 5. Current Vehicle Inspection Report Thank you again for choosing Project Amistad for your non-emergency medical transportation needs. We look forward to working with you. Cordially, Project Amistad SAU Department Welcome Letter 01/13/2017
Individual Transportation Participant (ITP) Enrollment Checklist Use this checklist to make sure all the items needed to sign up to be an ITP are completed and submitted. No trips will be authorized until all documents have been approved. For help filling out these forms, call Project Amistad Contact Center at 877-633 - 8747. A copy of your completed ITP Information Page (Please fill out everything, and mark N/A if a question does not apply.) A copy of your completed Client/ITP Information Page A copy of your current and valid Driver s License A copy of your current and valid auto insurance card A copy of your Social Security card A copy of vehicle registration and inspection Important: The name listed on your driver s license and Social Security card must be the same. Get your money faster with Electronic Funds Transfer (EFT) For faster payment with direct deposit to your bank account, fill out sections 1, 2, & 3 located on page 5 of this application and include a voided check. All forms must be mailed to Project Amistad ATTN: SAU Department PO Box 26807 El Paso, TX 79926 Note: Please retain a copy for your records. Project Amistad Page 1 01/13/2017
ITP Information Page The purpose of the form is to obtain data to sign up to be an ITP. You must fill out this entire form and sign it. Please use blue or black ink. Original signature only; copies or stamped signature will not be accepted. If you are driving for yourself or a family member, select Self. If you are driving for someone other than yourself or a family member, select Other. ITP Status: Self/Other: Self Other Telephone Number:(if we need to contact you) Must match Driver s License Last Name: First Name: Middle Initial: Social Security Number:(Please attach copy of card) Date of Birth: Driver s License Number: (Please attach a copy of driver s license). License Issue Date: License Expiration Date: Physical Address: This is where you live. (You must give a street address. PO boxes will not be accepted.) Number, Street, City, State, and Zip Code Mailing address: Number, Street, City, State, and Zip Code. Important: the name on your driver s license, social security card must be the same. Vehicle & Insurance Information Vehicle Identification Number (VIN): Please provide VIN of vehicle used to transport. License Tag: Auto Insurance Policy Number: Please attach a copy of insurer insurance card. The vehicle used to transport the client must be listed on insurance policy. Policy Issue Date: Policy Expiration Date: Project Amistad Page 2 01/13/2017
Client/ITP Information Page If you are driving yourself or family members only, fill out Section 1, leave Section 2 blank. If you are driving a person other than yourself or a family member, fill out Section 1 and Section 2. Section 1 Client Name: (the person you will be driving) Medicaid ID #: Client DOB: Relationship to ITP: Family Member Non-Family Member Self Section 2 (Facts about the ITP) Are you currently charged with or have you even been convicted of a crime (excluding Class C misdemeanor traffic citations)? Convicted means that: (a) A judgment of conviction has been entered against an individual by a Federal, State or local court, regardless of whether: (1) There is a post-trial motion or an appeal pending; or (2) The judgment of conviction or other record relating to the criminal Yes conduct has been expunged or otherwise removed; (b) A Federal, State or local court has made a finding of guilt against an individual; (c) A Federal, State or local court has accepted a plea of guilty or nolo contendere by an individual, or (d) An individual has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld. If Yes, fully explain the details including date, the state and county where the conviction occurred, the cause number(s), and specifically what you were convicted of. (attach additional sheets if necessary) No Project Amistad Page 3 01/13/2017
Terms and Conditions of Participation Terms and Conditions of Participation 1. Before an ITP drives a client, the client must get approval for the ride from Project Amistad. The client must call 1-877-633-8747 (MTO) to get this approval prior to the trip otherwise the ITP will not get paid. 2. The client must have the doctor sign the ITP Service Record/Claim Form and the ITP must sign the ITP Service Record/Claim Form. 3. The mileage reimbursement (payment) amount is based on a mileage calculation computed by Project Amistad using a nationally recognized system of the shortest distance of the trip and not on the number of clients who are given a ride. The ITP will be paid based on the determined mileage at the vehicle mile rate set by the Texas Legislature for state employees that is in effect at the time of the ride. 4. All payments to an ITP will be reported to the Internal Revenue Service (IRS). 5. The ITP must maintain a current and valid driver s license, vehicle insurance, vehicle inspection and vehicle registration during each ride. 6. The claim form must be submitted within 95 days from the date of the ride. Attestation: I attest that I have read the terms and conditions of participation as an Individual Transportation Participant (ITP) and that the information provided in this application is true and correct. I understand that I must comply with the terms and conditions of participation and maintain documentation to support any mileage reimbursement claim and that HHSC or Project Amistad reserves the right to request and validate documentation being relied upon to support mileage reimbursement claims. Signature of Individual Transportation Participant (ITP) Date Project Amistad Page 4 01/13/2017
Electronic Funds Transfer (EFT) / ADP ALINE Card To enroll in EFT or ADP complete the section below and attach a voided check or a signed letter from your bank on bank letterhead. Please check which would be of your preference, ADP card or Electronic Funds Transfer. For ADP preference, fill out only Section 1 and Section 3. For EFT option fill out sections 1-3 Section 1. Type of Authorization: EFT ADP Aline Card *Last Name: *First Name: *Middle Initial: *Address: Street, City, State, and Zip Code. *Telephone Number: *Social Security Number: *DOB: mm/dd/yyyy *Driver s License #: / / Section 2. Bank Information: (Fill out Section 2 if you prefer EFT and send in with a voided check) *Account Type (Check one): Checking Savings *Bank Name: *Bank Telephone: *Bank Address: *ABA/Transit Number (Routing): *Bank Account Number: Section 3. *Please check disclosure next to option you have preferred to use for deposit of your reimbursement* EFT: I hereby authorize Project Amistad to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I understand that I am responsible for the validity of the information on this form. If the company erroneously deposits funds into my account, I authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited. I understand that payment of 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. I will continue to maintain the confidentiality of records and other information relating to client in accordance with applicable state and federal laws, rules, and regulations. ADP: By accepting and using my ALINE Card, I agree to be bound by the terms and conditions outlined in the ALINE Cardholder Agreement. I hereby authorize ADP to credit any accounts owed to me, as instructed by Project Amistad, by initialing credit entries to my ALINE Card. In the event that ADP loads funds erroneously to my ALINE Card, I authorize ADP and Project Amistad to debit my card for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until ADP has received written notice from me of its termination in such time and in such manner as to afford ADP reasonable opportunity to act on it. I agree that I have reviewed and understand the ALINE Cardholder Fees Summary. *Signature: *Date: Project Amistad Page 5 01/13/2017
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NOTICE BACKGROUND AUTHORIZATION FORM In connection with your application and/or contract with (Project Amistad) this notice is provided to inform you that a consumer report and/or investigative consumer report, as defined by the Fair Credit Reporting Act, may be obtained from a consumer reporting agency for employment purposes. These types of reports may include information as to your character, general reputation, personal characteristics and mode of living, whichever are applicable. The report may also contain information about you relating to criminal history, credit history, driving and/or motor vehicle records, social security verification, verification of your education or employment history and other background checks. They may involve interviews with sources such as your neighbors, friends or associates. You have the right, upon written request made within a reasonable amount time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report to Crimcheck.com, 17295 Foltz Industrial Parkway, Suite B, Strongsville, OH 44149 [1-877-992-4325]. For information about Crimcheck.com s privacy practices, see www.crimcheck.com. The scope of this notice and authorization is not limited to the present and, if hired, will continue and allow Employer to conduct future screenings for retention, promotion or reassignment, unless revoked by you in writing. Employer also reserves the right to share such reports with a thirdparty for whom you will be placed to work as a representative of Employer, if applicable. Acknowledgement and Authorization You hereby authorize, without reservation, the obtaining of a consumer report and/or investigative consumer report at any time after receipt of this authorization and during the course of your employment, to the extent permitted by law. You also confirm your understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a representative of Employer, if applicable. Minnesota & Oklahoma applicants or employees only: Under state law you have a right to receive a copy of your consumer report, free of charge, if one is requested by Employer. By checking yes, a copy will be provided to you at the address you provide on this notice. I would like to receive a copy of my consumer report: Yes No New York applicants or employees only: Under state law you have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting Crimcheck.com directly. You also acknowledge receipt of a copy of Article 23-A of the New York Correction Law by signing this notice. Washington State applicants or employees only: Under state law you have a right to request a copy of the Washington Fair Credit Reporting Act s disclosures to consumers (RCW 19.182.070) by contacting Crimcheck.com directly. California, Maine applicants or employees only: Under state law you have a right to receive a copy of your investigative consumer report and/or consumer credit report, free of charge, if one is requested by Employer. By checking yes a copy will be provided to you at the address you provide on this Notice. I would like to receive a copy of my consumer report: Yes No *Signature: *Date: *Name: *SSN - - **Previous Names Used: (Within the past 7years) *Current Home Address: Street Address (No P.O. Boxes) City State Zip Code County *How long have you lived at current address? **Date of Birth: / / Driver s License Number: State: *Have you ever been convicted of a crime other than minor traffic offenses within the past seven years? Y N If yes, provide explanation: *Year of Offense: County offense was committed: Offense Description: City offense was committed: ** Crimcheck.com will only use this information for background screening purposes and no other purpose. Project Amistad Page 7 01/13/2017
ITP Service Record Client Name: Client Telephone: Client Medicaid: ITP Name: ITP Telephone: ITP MTI Number: Trip #1 From: To: Miles: Amount: From: To: Miles: Amount: Authorization Number: Appointment Date/Time: Total Miles: Total Amount: Health Care Provider NPI: Health Care Provider Telephone: Health Care Provider Name: I certify that this patient was seen for a Medicaid/CSHCN covered health-care service. Signature & Title of Health-care Provider: Date Signed: Trip #2 From: To: Miles: Amount: From: To: Miles: Amount: Authorization Number: Appointment Date/Time: Total Miles: Total Amount: Health Care Provider NPI: Health Care Provider Telephone: Health Care Provider Name: I certify that this patient was seen for a Medicaid/CSHCN covered health-care service. Signature & Title of Health-care Provider: Date Signed: AFFIDAVIT: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment of this claim is from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. I hereby certify that this claim contains no willful misrepresentation or falsification and that the information I have given is true and correct to the best of my knowledge and belief. I attest that I have complied with all of the provisions of the Individual Transportation Participant Agreement when providing the transportation services for which I am seeking reimbursement. Signature of Individual Transportation Participant (ITP) Date All forms must be mailed to Project Amistad Project Amistad PO Box 26807, El Paso, TX 79926 FAX: 915-626-5422 Email: itpservices@projectamistad.org Note: Please retain a copy for your records