APPLICATION FOR NON

APPLICATION FOR NON-EMERGENCY TRANSPORTATION (NET) FOR HEALTH CARE SERVICES

Download and complete the above APPLICATION, attach the required verification from your HEALTH CARE PROVIDER, and send or bring all information to:

BERGEN COUNTY BOARD OF SOCIAL SERVICES (BCBSS)
216 ROUTE 17 NORTH
ROCHELLE PARK, NJ 07662
ATTENTION: MEDICAL TRANSPORTATION UNIT

IMPORTANT!

YOUR APPLICATION WILL NOT BE PROCESSED UNLESS YOU COMPLETE IT IN FULL AND ATTACH THE REQUIRED VERIFICATION FROM THE HEALTH CARE PROVIDER.

YOU MUST BE RECEIVING MEDICAID AND HAVE A CURRENT MEDICAID NUMBER IN ORDER TO APPLY FOR NET SERVICES.

AN APPLICATION IS CONSIDERED VOID IF NOT COMPLETED IN FULL WITH REQUIRED VERIFICATIONS AND RETURNED TO BCBSS WITHIN 30 DAYS FROM THE DATE SENT TO YOU.

When you send in your completed application with the verification from your health care provider, BCBSS staff will evaluate your eligibility for the NET program within 30 days from the date the application is received at the BCBSS office. Part of the evaluation includes whether you require transportation for health care. Please review the following information:

If your Health Care Provider is within walking distance to your home and you are able to walk to this location, BCBSS will not pay for NET services.

If you are able to use Public Transportation (a bus) and the bus route is available to your home and to the location of health care provider, you will be required to use the bus. In this case, BCBSS will reimburse you the cost of your transportation.

If you are able to drive yourself to the health care provider, BCBSS will reimburse you at the rate of $.25 per mile.

If there is someone who is willing to use their car to drive you to your health care provider, BCBSS will negotiate with that person a mutually acceptable fee for their services.

If none of the above apply to your situation, BCBSS will try to arrange for a volunteer to transport you. If a volunteer is not available, BCBSS will try to arrange an alternative mode of transportation.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL (201) 368-4360

LIHEAP

The Low Income Home Energy Assistance Program (LIHEAP) provides assistance to help low income households pay home heating costs. Households with their heat included in their rent are also eligible for assistance. In addition, households may also be eligible for medically necessary cooling assistance and emergency heating assistance.

To see if you may qualify click on NJ Helps.ORG.

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