List of Credentialing Documents Required for Ohio:
Ambulette/Ambulance Company
Veyo will require proof of licensure from State of Ohio EMS Medical Transportation
- Providers are required to show proof of EMS Licensure and be enrolled with Medicaid ODM.
- Proof of licensure will require the provider to complete attestation. (Attached)
- Driver and Vehicle documents are not required once Veyo has validated the proof of EMS licensure and ODM State Medicaid ID.
- Company Documents
- See requirements below
- Vehicle Documents
- Only vehicle demographic form for Ambulette/Ambulance
- Sedan/Ambulatory non-wheelchair vehicles see below
- Driver Documents
- Only vehicle demographic form for Ambulette/Ambulance drivers
- Sedan/Ambulatory non-wheelchair drivers see below
Company Documents
- National Provider ID Number (Register here)
- Disclosure of Ownership - Corporate (Form Attached)
- Drug-Free Workplace Statement (Form Attached)
- Acknowledgment of Company policies (Attached)
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- Maintenance of documentation for 10 years
- Attestation of LEIE, SAM, EPLS exclusion
- Driver Identification
- Daily Vehicle Inspection
- English Language Communication
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- W9 - Corporate (Attached)
- Bank Letter Verification / Voided Check to confirm bank account information
- Direct Deposit Banking Information (Form Attached)
- Business License
- Driver List
- Vehicle List
- Veyo FWA Attestation (Form Attached)
- Transportation Provider Manual (Attached)
- MTM - ODM/ODA certification/validation and active/approval status (if applicable)
Insurance Documents
Certificate of Auto Liability Insurance (Example Attached)
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- Please make sure that there is an "X" under the "Addl Insd" column
- It must have Veyo listed as the certificate holder. Address: 4250 Executive Square, Suite 200, La Jolla, CA 92037
- It must have Medical Transportation Management, Inc. and all Affiliates listed as the certificate holder. Address: 16 Hawk Ridge Circle Lake St. Louis, MO 63367
- It must have a minimum coverage of five hundred thousand dollars ($500,000).
- Certificate of General Liability Insurance
- Please make sure that there is an "X" under the "Addl Insd" column
- It must have Veyo listed as the certificate holder. Address: 4250 Executive Square, Suite 200, La Jolla, CA 92037
- It must have Medical Transportation Management, Inc. and all Affiliates listed as the certificate holder. Address: 16 Hawk Ridge Circle Lake St. Louis, MO 63367
- It must have a minimum coverage of five hundred thousand dollars ($500,000).
- Commercial Auto and General Insurance Endorsement (Example Attached)
- Veyo will require an endorsement for both Auto Liability and General Liability
- It must have Veyo listed as the additional insured. Address: 4250 Executive Square, Suite 200, La Jolla, CA 92037
- It must have Medical Transportation Management, Inc. and all Affiliates listed as the certificate holder. Address: 16 Hawk Ridge Circle Lake St. Louis, MO 63367
- Workers Compensation
- Worker's Compensation in line with the state standards.
Driver Documents
- Complete Driver List (Attached)
- Current Driver's License
- Background Check - with no felony convictions
- Must be completed by an approved agency
- Motor Vehicle Record
- Drug Screen
- Driver Compliance Communication (Attached)
- Driver Demographic Information - Must be filled out in OurRecords (Credentialing Platform) driver profile
Training Requirements
*Copies of Certificates must be provided for each driver
- CPR Training Certification (Active Certification issued by a licensed Instructor)
- First Aid Training Certification (Active Certification issued by a licensed Instructor)
- Credentialing and Annual Driver Training Certification (Attached)
Vehicle Documents
- Vehicle List (Attached)
- Vehicle Insurance Card
- Vehicle Registration
- Vehicle Data - Must be filled out in OurRecords (Credentialing Platform) vehicle profile
- Vehicle Inspection - Completed by Veyo (Attached)