<p> Transportation Provider Questionnaire</p><p>Please type or write legibly and complete all information as thoroughly as possible.</p><p>GENERAL INFORMATION Company Legal Name:</p><p>Type of Business: Corporation Partnership LLC Sole Proprietor Federal Tax ID #: If sole proprietorship, provide SSN#: If Not For Profit, provide “Tax Exempt” #:</p><p>State/Commonwealth Medicaid Provider Number (Mandatory information if this has been assigned to your company):</p><p>Street Address:</p><p>City: State: Zip:</p><p>Primary Phone: Secondary Phone: Fax:</p><p>How long have you provided Non-Emergency medical What is the name of your routing and dispatching Transportation (NEMT) services? software?</p><p>If none, would you consider What is your primary communication system with vehicles? (Check all that apply) implementing one? 2-Way Radio Cell Phone Pager Computers None No Yes SERVICE AREA & AVAILABILITY Base County: Current, regular service area:</p><p>Occasional areas you serve (areas you are willing to provide service to on an occasional basis):</p><p>Regular business office hours: Days and hours of regular transportation service:</p><p>Are you willing to accept ASAP, same-day requests? No Yes</p><p>About how many trips do you provide each week? How many trips would you like to provide each week? Medical: Medical: Other: Other: </p><p>What is the maximum number of passengers you are willing to transport from the same pick-up location to the same drop off destination? Also, specify any additional charges that apply.</p><p>RATES Ambulatory Base Rate: Number of miles included in base: Ambulatory Per Mile:</p><p>Wheelchair Base Rate: Number of miles included in base: Wheelchair Per Mile:</p><p>MTM Transportation Provider Questionnaire Page 1 of 4 SERVICES & VEHICLES Indicate which services you provide and list the number of each type of vehicle you use in regular service. Taxi Quantity: Med Car (sedans used for medical trips only) Quantity: Van Quantity: Medical Facility Based Service Quantity: Non-Emergency Ambulance Based Service Quantity: Community Service Agency Quantity: Paralift Van Service Quantity: Public Fixed Bus Service Quantity: Stretcher Quantity: Other (specify): Quantity: List your vehicles below. Use a separate sheet of paper as needed. Vehicle Type Vehicle Year & Make Colors/Markings Number of Passengers</p><p>ADDITIONAL SERVICES Are you willing to place a phone call to each passenger to confirm trip details? No Yes Are your drivers fluent in any foreign languages? No Yes. Language(s): Can you provide attendants to stay with the passenger during the entire medical appointment, if necessary? No Yes Do you contract with a service that provides attendants? No Yes If you use sedans/med cars, will you transport and assist a person who is in a wheelchair, but who is capable of “scooting” from the Yes chair to the vehicle. Assistance includes folding the wheelchair Yes, but an additional charge applies and placing it in the trunk. (Note: This is not appropriate for van use because a stowed wheelchair can become a flying/harmful object in the No event of a crash if it is not properly secured.) Will your drivers offer any of the following assistance to ambulatory passengers (frail, elderly, etc.) if necessary? From the front door Up and down steps. Step limit: In an elevator To a check-in desk NO ASSISTANCE OFFERED Will your drivers offer any of the following types of assistance to wheelchair passengers if necessary? From the front door Up and down steps. Step limit: In an elevator To a check-in desk NO ASSISTANCE OFFERED</p><p>Indicate what types of child seats No child seats available. you provide and the quantity you Do not currently provide, but will consider purchasing. have on hand. (Note: If you do not Child Car Seats Quantity: have child restraint seats, you may not accept any trips that ask for a Infant Car Seats Quantity: child seat to be provided.) Booster Car Seats Quantity: CONTACT INFORMATION</p><p>MTM Transportation Provider Questionnaire Page 2 of 4 Names of all contacts for your business Primary Contact Name: Title: Phone: Email:</p><p>Contact Name: Title: Phone: Email:</p><p>Contact Name: Title: Phone: Email:</p><p>OWNERSHIP, MANAGEMENT, & SUBCONTRACTORS List all company owners. Include any individual who holds 5% or more shares in the company Name: Relation to Other Owners: Address:</p><p>Name: Relation to Other Owners: Address:</p><p>Name: Relation to Other Owners: Address:</p><p>List Company Agents and Managing Employees (including, but not limited to, Officers and Directors) Name: Role/Title:</p><p>Name: Role/Title:</p><p>Name: Role/Title:</p><p>Name: Role/Title:</p><p>Have any of the above named individuals (including, but not limited, to owners, officers, directors, and managers) ever been terminated from a State or Federal program, or convicted of a criminal offense related to that person’s involvement in any program under Medicaid, Medicare, or the Title XX services program since the inception of those programs? If yes, give the names of the person(s) and descriptions of offense(s): No </p><p>Yes</p><p>Has the company had business transactions with any subcontractor totaling more than $25,000 during the last 12 months? If yes, list the subcontractor’s name and address, and the subcontractor’s ownership or control No interest for each subcontractor:</p><p>Yes</p><p>Has the company had any significant business transactions with a wholly owned supplier or with any subcontractor during the preceding 12 month period? If yes, give the information below for each supplier or contractor:</p><p>No</p><p>Yes</p><p>BUSINESS CERTIFICATIONS & ACCREDITIONS</p><p>MTM Transportation Provider Questionnaire Page 3 of 4 Does your business qualify as a MBE? No Yes MBE (Minority- If Yes, is your company a Certified MBE? No Yes Owned If so, please provide us with your certification number Certificate #: Business and a copy of your certificate. Enterprise) If not, are you interested in becoming certified? No Yes</p><p>Does your business qualify as a WBE? No Yes WBE If Yes, is your company a Certified WBE? No Yes (Women- Owned If so, please provide us with your certification number Certificate #: Business and a copy of your certificate. Enterprise) If not, are you interested in becoming certified? No Yes</p><p>Does your business qualify as a DBE? No Yes</p><p>DBE If Yes, is your company a Certified DBE? No Yes (Disadvantage d Business If so, please provide us with your certification number Certificate #: Enterprise) and a copy of your certificate. If not, are you interested in becoming certified? No Yes</p><p>Does your business qualify as a SDVOSB? No Yes</p><p>SDVOSB If Yes, is your company a Certified SDVOSB? No Yes (Service If so, please provide us with your certification number Disabled and a copy of your certificate. (DD Form 214, Certificate #: Veteran- Certificate of Release or Discharge from Active Duty) </p><p>Owned Small and a copy of the state Service Disabled Veteran Business) Business Preference form. If not, are you interested in becoming certified? No Yes</p><p>The applicant attests to the correctness/completeness of this questionnaire. All information is kept confidential. Signature: Date:</p><p>Return this completed form via email to [email protected] or to: MTM, Network Management 16 Hawk Ridge Drive Lake St. Louis, MO 63367</p><p>MTM Transportation Provider Questionnaire Page 4 of 4</p>