DMS-632 - Arkansas Medicaid

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Arkansas Division of Medical Services. DDTCS Transportation Survey ... Vehicle Repairs/Maint. $. Gas and Oil. $. Vehicle Rent. $. Vehicle Insurance. $ ...


Arkansas Division of Medical Services

DDTCS Transportation Survey

DDTCS Transportation Provider Name______________________________

Medicaid DDTCS Transportation Provider Number_______________________________

Fiscal Reporting Period____________ through_____________

(Information not required if less than 6 months)

Total DDTCS Passenger Miles________________

Total DDTCS Non-Passenger Miles__________________

Total DDTCS Miles________________________

Unduplicated Count of Medicaid DDTCS Clients Transported__________

Unduplicated Count of NonMedicaid DDTCS Clients Transported__________

Medicaid DDTCS Transportation Revenue_________________ NonMedicaid DDTCS Transportation Revenue_________________ Total DDTCS Transportation Revenue____________________

|Direct Costs – DDTCS Transportation | | |Drivers Salaries |$_______________ | |Drivers Fringes/Payroll Taxes |$_______________ | |Escorts Salaries |$_______________ | |Escorts Fringes/Payroll Taxes |$_______________ | |Other Salaries |$_______________ | |Other Fringes/Payroll Taxes |$_______________ | |Program Supplies |$_______________ | |Vehicle Repairs/Maint. |$_______________ | |Gas and Oil |$_______________ | |Vehicle Rent |$_______________ | |Vehicle Insurance |$_______________ | |Vehicle Depreciation |$_______________ | |Vehicle Interest |$_______________ | |Training |$_______________ | |Direct Utilities |$_______________ | |Direct Telephone |$_______________ | |Direct Building Rent |$_______________ | |Direct Building Utilities |$_______________ | |Direct Building Depreciation |$_______________ | |Direct Building Interest |$_______________ | |Other - ____________________ |$_______________ | |Other - ____________________ |$_______________ | |Other - ____________________ |$_______________ | | | | |Total Direct Costs – DDTCS Transportation |$_______________ | | | | | | | |Indirect/Overhead Costs – DDTCS Transportation|$_______________ | | | | |Total DDTCS Transportation Costs |$_______________ |

(Report Cost in Dollars Only, No Cents)

DMS-632 (7-1-00)

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