Wisconsin In-Network Transportation Provider Checklist

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Participants within three hours after accepting the trip reservation fromLGTC.viii) No Participant in a multi-load vehicle shall remain in the vehicle morethan forty-five (45) minutes longer that the average travel time for directtransport from point of pick-up to destination.ix) No more than 2% of Provider’s assigned trips shall be late or missedpick-ups. Providers with greater than 1% of their assigned trips as missedpick-ups may have their trips reduced. Habitual failure to meet thisstandard shall be a material breach of this Agreement and may result intermination of this Agreement.x) An adult escort at least eighteen (18) years of age or older shall bepermitted to accompany a child under eighteen (18) years of age, and insome cases, an adult escort may be required to accompany the child.Provider shall, at no additional charge, transport an adult escort of aminor Participant if and as directed by LGTC. A minor Participant shallbe transported in the rear seat or compartment of the vehicle and shall notbe permitted to travel as a front seat passenger.xi) A transportation attendant or personal assistant may ride with aParticipant if necessary to assist the Participant. The attendant or assistantshall assist the patient and the driver as requested.xii) Provider must allow service animals in the vehicle, as needed; however,other animals shall not be allowed on board the vehicle.xiii) Provider shall confirm the scheduled pick-up time with the Participant atleast 24-hours prior to the scheduled pick-up.c) General Vehicle Requirements. All vehicles utilized by Provider in theperformance of services under this Agreement must meet the requirements listedbelow. Each vehicle is subject to an initial and bi-annual inspection by LGTC aswell as interim inspections as required by LGTC in its sole discretion. Allvehicles must be made available to Client or its agent(s) for inspection at anytime. Inspections performed by LGTC do not replace or excuse the Providerfrom obtaining vehicle safety inspections as required by state or local law.Documentation of inspections performed by other agencies may suffice as longas LGTC and Client have access to the inspection records, and the inspectionstandards meet or exceed those of this Agreement. Any vehicle found noncompliantwith the following inspection standards, Wisconsin licensingrequirements, safety standards, Wisconsin Highway and TransportationDepartment, or ADA regulations, or other State or Federal laws or regulationsshall be immediately removed from service and shall pass a re-inspection beforeit may be used to provide transportation services for Participants under thisAgreement.i) Vehicles shall comply with the Americans with Disabilities Act (ADA)Accessibility Specifications for Transportation as well as Federal TransitAdministration (FTA) regulations, as applicable for the type of vehicleWisconsin NET ProgramVersion: March 25 2011Page 6
utilized by Provider.ii) The number of occupants in the vehicle, including the driver, shall notexceed the vehicle manufacturer’s approved seating capacity. Allvehicles shall have an available seat, with operable seatbelt, for eachpassenger that is securely fastened to the floor of the vehicle.iii) All vehicles shall have adequately functioning heating and airconditioningsystems and at all times shall maintain a temperature that iscomfortable to the Participant.iv) All vehicles shall have functioning seat belts and restraints as required byapplicable law. All vehicles shall have an easily visible interior sign thatstates: “ALL PASSENGERS SHALL USE SEAT BELTS”. Seat beltsmust be stored off the floor when not in use.v) Provider shall have at least two seat belt extensions available in eachvehicle if the vehicle’s standard seatbelts are not of “extended” length.vi) All vehicles shall be equipped with at least one seat belt cutter that is keptwithin easy reach of the driver for use in emergency situations.vii) All vehicles shall have an accurate, operating speedometer and odometer.viii) All vehicles shall have two exterior rear view mirrors, one on each side ofthe vehicle.ix) All vehicles shall be equipped with an interior mirror for monitoring thepassenger compartment.x) The exterior of all vehicles shall be clean and free of broken mirrors orwindows, excessive grime, major dents, or paint damage that detractsfrom the overall appearance of the vehicles.xi) The interior of all vehicles shall be clean and free of torn upholstery, tornor damaged floor or ceiling covering, damaged or broken seats,protruding sharp edges, dirt or litter, oil, grease, hazardous debris, orunsecured items.xii) Vehicles and all components must comply with or exceed themanufacturers, state and federal, safety and mechanical operating andmaintenance standards for the particular vehicles and models used underthis contract.xiii) All vehicles shall have Provider’s business name and telephone numberdisplayed on at least both exterior sides.xiv) The vehicle license number and LGTC’s toll-free and local phonenumbers shall be prominently displayed in the interior of each vehicle.This information, together with complaint procedures provided by LGTCshall be available in writing and stored in a clearly visible location in eachvehicle for distribution to Participants upon request.xv) Smoking shall be prohibited in all vehicles at all times. All vehicles shallhave an easily visible interior sign that states: “NO SMOKING”.xvi) All vehicles shall carry a vehicle information packet containing vehicleregistration, insurance card, and accident procedures and forms.xvii) All vehicles shall be equipped with a first aid kit stocked with antisepticcleansing wipes, triple antibiotic ointment, assorted sizes of adhesive andgauze bandages, tape, scissors, latex or other impermeable gloves andWisconsin NET ProgramVersion: March 25 2011Page 7
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5 and 6: Provider may be withdrawn by LGTC,
Page 7: ii)iii)iv)scheduled B-Leg pick up t
Page 11 and 12: • ADA regulations;• Client Cont
Page 13 and 14: vi)type of vehicle in which it is i
Page 15 and 16: and satisfactorily cleared a nation
Page 17 and 18: ix)a Participant, or in the presenc
Page 19 and 20: iv)Provider warrants that it has no
Page 21 and 22: a) name, date of birth and social s
Page 23 and 24: from establishing or maintaining se
Page 25 and 26: 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
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Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63:
Dear LogistiCare Transportation Pro
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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
Page 78 and 79:
LogistiCare Driver ListLegal name D
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Wisconsin In-Network Transportation Provider Checklist

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