HFS Transportation Provider Portal

Transportation Provider Details/Follow-up Information

Failure to provide adequate information may prevent us from investigating this complaint.

Title

Transportation Provider Name

Provider ID

Medicaid ID or NPI

Contact Name

Individual for HFS to follow-up with at Provider's Office

Phone Number

Preferred Method of Contact

Facility/Complaint Information

Please provide as much detailed information about the complaint as possible.

Facility Contact Name

Facility Contact Phone

Please select the Hospital or Long Term Care Facility not being compliant.

Hospital Facilities

Long Term Care Facilities

Date of Service

Issue Type

Issue Summary

Please provide as much detailed information about the issue as possible.

Please provide examples of the PCS Form issues.

Attachments

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