1. (a) All transportation company drivers shall be participants with the broker.

2. (b) The broker shall acquire and store the following required documentation for all family and friend drivers:

   1. (1) A copy of the driver’s license of the driver(s);

   2. (2) A completed “Family and Friends Mileage Reimbursement Program New Driver Enrollment Sheet” (September 2025) agreeing to the following:

      1. a. “Participation in the Family and Friends Program is both voluntary and a privilege and that failure to comply with any of the rules of the program may result in my immediate termination from this milage reimbursement program;
      2. b. Medicaid fraud is a serious crime and fraudulent submissions for reimbursement under this program can result in criminal penalties up to 7 years in State prison;
      3. c. If I move I must update and provide proof of my new address to Medicaid before I submit my next reimbursement form;
      4. d. Driver must have a valid driver’s license in order to receive reimbursement under this program;
      5. e. Driving without a license, driving with a suspended license, or driving while designated as a habitual offender are all crimes in New Hampshire and submissions made under this program can and will be used against me in criminal proceedings;
      6. f. If the New Hampshire Department of Health and Human Service or its partners has reason to suspect any potential violations of the Family and Friends Program, I understand that my driver’s history, motor vehicle records, and/or my criminal background may be checked;
      7. g. Having a criminal history or driving records does not necessarily prevent me from participating in this program;
      8. h. My participation in this program will be governed in accordance with the Department of Health and Human Services’ Administrative Rule He-W 574.”; and
      9. i. “That all information contained in this application and the information in the accompanying documents is true and accurate and that any material falsities contained herein may result in a prosecution for false swearing under RSA 641:3.”;

   3. (3) A completed “Request for Reimbursement of Medical Transportation by Private Car” (September 2025) signed by:

      1. a. The member and certifying that:

         “The information on this form is true, accurate, and complete. I understand that payment of this claim may be from Federal and State funds and that any false or altered claims, statements, documents, or the concealment of material fact may be prosecuted under applicable Federal and State laws. I agree to accept transportation payment as payment in full but understand that I have the right to appeal the reimbursement amount”; and

      2. b. The medicaid provider and certifying that:

         “The patient named above visited my office/clinic/pharmacy for non-emergency medical appointment(s) or Medicaid covered pharmaceuticals on the date(s) as noted.”; and

   4. (4) A copy of a review of the Office of Inspector General list of excluded individuals and entities, pursuant to He-W 574.03(c), at start of service and monthly thereafter.

3. (c) The broker shall acquire and store the following documentation for all transportation company drivers for a period of 6 years:

   1. (1) A completed, signed, and dated credentialing packet from the transportation company;
   2. (2) Proof of a valid driver’s license;
   3. (3) A copy of the document received from the IRS which provided the driver’s federal tax ID number;
   4. (4) A completed IRS W-9 form at the time of enrollment;
   5. (5) A copy of the document received from the IRS which indicates the applicant’s non-profit tax-exempt status, if applicable;
   6. (6) Proof of automobile liability insurance;
   7. (7) Updated proof of insurance at the time it is renewed, and at any other time when a change in status has occurred;
   8. (8) Review of the Office of Inspector General list of excluded individuals and entities upon hire and monthly checks;
   9. (9) Background checks;
   10. (10) Records of recipient complaints including actions taken to investigate and resolve complaint;
   11. (11) Training records;
   12. (12) Dispatch travel logs including driver name, transportation company name, recipient name, and date of service, with signature log of all parties;
   13. (13) Billing and payment records; and
   14. (14) Proof that the vehicle is safe for transporting passengers.

4. (d) Wheelchair van drivers shall:

   1. (1) Retain and submit the following documentation when requested, to the broker:

      1. a. Proof that the vehicle was registered in accordance with RSA 261:40 during the time of medicaid wheelchair van service; and
      2. b. Proof of vehicle insurance during the time period that services were delivered; and
   2. (2) Comply with all applicable requirements of 49 CFR 37 and 49 CFR 38.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04 New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.03), eff 10-1-25, EXPIRES: 10-1-35