Logisticare Gas Form PDF Details

When residents of South Carolina find themselves needing to travel for medical appointments, the Logisticare Gas Mileage Reimbursement Trip Log emerges as a crucial form, streamlining the process of seeking fuel cost recompenses. This document, diligently designed to be sent to the LogistiCare Claims Department in College Park, Georgia, ensures that individuals who drive themselves or others for medical services can recuperate some of the transportation expenses incurred. With spaces provided for extensive details such as the driver's name, their relationship to the member, contact information, and the specifics of each trip, including dates, job numbers, medical provider details, and the mileage covered, it encapsulates all necessary data to facilitate a smooth reimbursement process. Crucially, the form mandates the endorsement of a physician or clinician for each service date, underscoring the authenticity of the travel claim. A noteworthy point is the verification step by LogistiCare, wherein each trip is confirmed with the respective physician's office before any payment is processed, adding an extra layer of validation. Embodying a straightforward yet pivotal document, the Logisticare Gas Mileage Reimbursement Trip Log reflects an understanding of the financial burdens that can accompany medical care, offering a method to alleviate some of these stresses for South Carolinians.

QuestionAnswer
Form NameLogisticare Gas Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslogisticare, sc gas mileage, south carolina reimbursement, logisticare gas reimbursement

Form Preview Example

SOUTH CAROLINA GAS MILEAGE REIMBURSEMENT TRIP LOG

Must be sent to: LogistiCare Claims Department 503 Oak Place, Suite 550 College Park, GA 30349

DRIVER NAME:

 

 

 

 

RELATIONSHIP TO MEMBER:

 

 

DRIVER MAILING ADDRESS:

 

 

 

 

DRIVER PHONE #:

 

 

 

CITY/STATE/ZIP:

 

 

 

 

 

 

 

 

MEMBER NAME (If different from Driver):

 

 

 

MEMBER ID#:

 

 

 

 

 

 

Trip Date

Trip/Job #

Medical Provider Name & Phone #

Physician/Clinician Signature*

Total Miles

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

Phone #:

*Each date of service must have a physician or clinician signature in order for reimbursement to be approved. NOTE: Each trip will be confirmed with the physician’s office before payments will be made

Do not write in this space.

Total mileage to be paid:_________________________

Total amount for this invoice:______________________

Batch #: ___________

Batch date:_______________

I hereby certify the information contained herein is true, correct and accurate. Signature

Version 1.0 2011

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