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Provider Forms - Various Consumer Related forms for MATP Providers

  • MATP Application
    Consumer is required to complete and sign within 30 days of being deemed eligible.

  • Authorization for Release of Information
    Consumer completes at the time of registration.

  • MATP Policy Acknowledgement
    Consumer initials upon receipt of MATP policies.

  • Mode of Transportation Determination
    Consumer and Grantee complete at the time of registration to determine the least costly and most appropriate mode of transportation that will meet that individual consumer’s current level of mobility and functional independence.

  • Mileage Reimbursement Request
    Consumer completes in order to receive reimbursement for costs incurred for mileage, parking and toll when a private vehicle is used for transportation to medical appointments.

  • Incident Report
    Grantee completes within 48 hours of an incident involving the consumer and/or other individuals.

  • Written Notice
    Grantee issues to consumer when services are determined, changed, denied, suspended or terminated. The notice informs the consumer of their right to appeal.

  • CAO Referral Form
    Fillable PDF of County Assistance Office Referral form.

  • Managed Care Referral Form
    Fillable PDF of Managed Care Referral form.

  • OIG Referral Form
    Grantee completes in instances of suspected inadequate, incomplete, inconsistent, or indeterminate information.