New Hampshire Medicaid uses one universal form, adopted under rule He-W 574, to record a member's mobility needs and the transportation mode required for medical rides, whichever plan the member is in. A health care professional marks the mode, from car to stretcher van or non-emergency ambulance, plus mobility limits, devices and the level of assistance. It goes to the plan's transportation broker before rides are scheduled.
Any health care professional working with the member, such as an RN, MD, health plan care manager, case manager or nursing facility staff, completes, signs and dates it with title and NPI. The member's plan is checked at the top.
Download the current version from the source each time; forms change without notice.
Mobility Determination for Non-Emergency Medical Transportation - Universal Form for All Medicaid Plans
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The form is intended to be valid indefinitely. If the duration of need is marked Permanent, a new form is only needed when the member's condition changes. If marked Temporary, the form should be updated annually. It can be replaced at any time by submitting a new form.
Any health care professional working with the member, including a health plan care manager or nursing facility staff. The signature block names examples such as an RN, MD, care manager or case manager, who must complete, sign and date the form and attest to the accuracy of the information.
Send it by fax or email to the transportation broker for the member's health plan before the ride is scheduled. Page 2 lists the broker contacts for AmeriHealth Caritas New Hampshire, NH Healthy Families, WellSense and NH Medicaid fee-for-service.