The ITP Service Record form serves as a critical tool in the management and reimbursement of transportation services for clients under Medicaid and the Children's Health Insurance Program (CSHCN). Focused on ensuring that clients receive timely and appropriate access to healthcare services, this form meticulously records each trip made, including details such as the client’s name, telephone, Medicaid information, the name and contact information of the individual transportation provider (ITP), miles traveled, and the amount claimed for each trip. A distinctive feature of this form is its emphasis on accountability and veracity, underscored by a section that requires health care providers to certify the necessity of the medical service, thereby validating the claim for transportation. Furthermore, it includes an affidavit by the transportation provider attesting to the accuracy of the information provided and the compliance with the terms of the Individual Transportation Participant Agreement. This comprehensive approach, aimed at preventing fraud and ensuring the efficient use of federal and state funds, underscores the rigorous process involved in claiming reimbursement for transportation services provided to Medicaid and CSHCN beneficiaries. Importantly, it also mentions the process for submission and recommends retaining a copy for records, highlighting the procedural and legal considerations inherent in the reimbursement process.
| Question | Answer |
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| Form Name | ITP Service Record Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 47 |
| Avg. time to fill out | 9 min 39 sec |
| Other names | logisticare transportation form, logisticare service record search, texas medicaid reimbursement for gas, itp service claim form |
ITP Service Record (Claim Form)
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ITP Name: |
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Trip #1
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I certify that this patient was seen for a |
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Medicaid/CSHCN covered |
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Trip #2 |
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Health Care Provider NPI: |
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I certify that this patient was seen for a |
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Medicaid/CSHCN covered |
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ITP Drivers: Please note that the allowable mileage that may be claimed for reimbursement is preprinted on the form.
AFFIDAVIT: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment of this claim is from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. I hereby certify that this claim contains no willful misrepresentation or falsification and that the information I have given is true and correct to the best of my knowledge and belief. I attest that I have complied with all of the provisions of the Individual Transportation Participant Agreement when providing the transportation services for which I am seeking reimbursement.
Signature of Individual Transportation Participant (ITP) |
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All forms must be mailed to Logisticare
ATTN: Claims
12234 N. I
Austin, TX 78753
Note: Please retain a copy for your records