Itp Service Record Form – Fill Out and Use This PDF

ITP Service Record (Claim Form)

Client Name:	Client Telephone:			Client Medicaid:
	(	)
ITP Name:	ITP Telephone:			ITP MTI Number:
	(	)

Trip #1

	From:			To:		Miles:		Amount:
	From:			To:		Miles:		Amount:
	Authorization Number:			Appointment Date/Time:		Total Miles:		Total Amount:
	Health Care Provider NPI:			Health Care Provider Telephone:		Health Care Provider Name:
			(		)
	I certify that this patient was seen for a			Signature & Title of Health-care Provider:			Date Signed:
			
	Medicaid/CSHCN covered health-care service.
	Trip #2
	From:			To:		Miles:		Amount:
	From:			To:		Miles:		Amount:
	Authorization Number:			Appointment Date/Time:		Total Miles:		Total Amount:
	Health Care Provider NPI:			Health Care Provider Telephone:		Health Care Provider Name:
			(		)
	I certify that this patient was seen for a			Signature & Title of Health-care Provider:			Date Signed:
				
	Medicaid/CSHCN covered health-care service.

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)

Date

All forms must be mailed to Logisticare

ATTN: Claims

12234 N. I -35, Suite 175

Austin, TX 78753

Note: Please retain a copy for your records