Try for free

NYS Medicaid Form 2020: Outside Common Medical Area

New York Medicaid requires this request when an enrollee needs transportation to care outside their common medical marketing area (CMMA), the area where the community usually gets its care. The referring physician explains whether the service is available locally and, if it is, why local care is inappropriate. Completing it does not guarantee that Medicaid-funded transportation outside the CMMA will be authorized.

Who completes it

The referring physician completes and signs the form with an NPI, and any staff member who helped is named on it. The accepting physician at the distant facility should not sign it.

Submitting and payment

How to submit it
Submit it through the Medical Answering Services practitioner portal, or fax the PDF version to the transportation manager, at least seven business days before the appointment.

Good to know

  • Continuity of care alone, without specific reasons the care must happen outside the CMMA, results in an immediate denial according to the form.
  • Include the medical justification and diagnosis with a care plan duration; any omitted information delays the determination.
  • Travel outside the CMMA is not authorized when the enrollee was noncompliant with local providers and cannot get local services because of their own actions.
  • The transportation manager may also ask the physician for a letter of medical necessity, and it notifies the enrollee of the decision.

Get the official form

Download the current version from the source each time; forms change without notice.

NYS 2020 (Outside Common Medical Area) Form

Official pagePDF

Fill it with Vero

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.

See how Vero Documents works

How this list is checked

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.

Frequently asked questions

Who signs the NYS 2020 out-of-area transportation form?

The referring physician. The policy says the form must be fully completed and signed by the referring physician, and that the accepting physician is not to sign it and authorize transportation to their own facility. The form also names any staff member who helped complete it.

When should the 2020 form be submitted?

The transportation manager asks for it seven business days before the appointment, to allow time for review, approval and arranging the trip. Missing information delays the decision, and the enrollee is notified of the determination once the request has been reviewed.

When is travel outside the common medical marketing area allowed?

Only when the needed care is not available within the CMMA, when a specialized regimen of care with a specific provider must continue, or in other circumstances unique to the enrollee that the transportation manager or Department of Health accepts. Otherwise the request is denied.