Compliance-Accident and Incident Report

Department of Health NEMT Accident and Incident Report
Please attach a copy of the police report or collision report. You can also email a copy to jen@volunteertransportation.org and honey@volunteertransportation.org.
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TRANSPORTATION PROVIDER INFORMATION
Company (VTC)
Contact Person
Phone Number
Medicaid Provider ID
Level of Service (if your company provides multiple levels of service, select the level in use during the event)
DESCRIPTION OF ACCIDENT/INCIDENT
County
Location Type
Address
If other, describe
Date

MonthDayYear
Date
Time
Driver Name
Driver's License Number
License Plate
Trip Invoice Number
Type of Accident/Incident
Were emergency services called?

YesNo
If yes, check all that apply

PoliceAmbulanceFireTow truck
Was a police report or MV-104A filed?

YesNo
Report Number
List the names of all vehicle occupants
Was there an injury to any party?

NoYes
If yes, please indicate the party and describe the injury:
Please describe the event in detail:
CERTIFICATION
I attest that this information is true to the best of my knowledge.
Reported by
Date

MonthDayYear
Date
Should be Empty:

Department of Health NEMT Accident and Incident Report