Wisconsin In-Network Transportation Provider Checklist

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LogistiCare Driver ListLegal name Driver's License # Expiration Date State of Drivers LicenseCompany Name
LogistiCare Vehicle ListMake Model Year VIN Tag TypeAmbulatorySeatsWheelchairPositions
Page 1 and 2:
Please return all documents to:1275
Page 3 and 4:
TRANSPORTATION AGREEMENT(the “Agr
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Provider may be withdrawn by LGTC,
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ii)iii)iv)scheduled B-Leg pick up t
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utilized by Provider.ii) The number
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• ADA regulations;• Client Cont
Page 13 and 14:
vi)type of vehicle in which it is i
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and satisfactorily cleared a nation
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ix)a Participant, or in the presenc
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iv)Provider warrants that it has no
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a) name, date of birth and social s
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from establishing or maintaining se
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the dispute shall be referred for b
Page 27 and 28: EXHIBIT ALIQUIDATED DAMAGESThe Part
Page 29 and 30: Requirement:Provider must perform t
Page 32 and 33: To determine the payment amount LGT
Page 34 and 35: Exhibit B - Execution PageLOGISTICA
Page 36 and 37: scope of the employment or other pr
Page 38 and 39: or created or received by BUSINESS
Page 40 and 41: presenting a preponderance of the e
Page 42 and 43: EXHIBIT EMedicare Advantage Program
Page 44 and 45: information and data necessary for:
Page 46 and 47: e reviewed and approved by Health P
Page 48 and 49: Non-Emergency Medical Transportatio
Page 50 and 51: LOGISTICARE INSURANCE CREDENTIALING
Page 52 and 53: Please describe your hours of opera
Page 54 and 55: Network Development503 Oak Place, S
Page 56 and 57: AFTER HOURS CONTACTINFORMATION SHEE
Page 58 and 59: Form W-9 (Rev. 1-2003) Page 2Exampl
Page 60 and 61: Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63: Dear LogistiCare Transportation Pro
Page 64 and 65: Electronic Data Interchange (EDI) A
Page 66 and 67: Date: __________________________Log
Page 68 and 69: Software User AgreementWHEREAS, Log
Page 70 and 71: III.OWNERSHIPThe Software is protec
Page 72 and 73: X. THIRD PARTY WEBSITESThe Software
Page 74 and 75: (B) The Content may not be copied,
Page 76 and 77: this Agreement, or the infringement
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Wisconsin In-Network Transportation Provider Checklist

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