Logisticare Gas Form PDF Details

Are you looking for a way to make sure that your medical transportation costs are quickly and easily covered? If so, then you should consider applying for Logisticare's Gas Form. This form is designed to help those with transportation needs receive reimbursement for their gas expenses, making the process streamlined and hassle-free. Continue reading to find out more about how this program can benefit individuals and families in need of assistance covering their medical travel costs.

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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