Logisticare Mileage Reimbursement PDF Details

Understanding the LogistiCare Mileage Reimbursement form is essential for anyone seeking compensation for transportation services provided to LogistiCare members. This crucial document, which must be sent to the LogistiCare Billing Department in Norton, VA, includes sections for the driver’s name, relationship to the member, contact information, and details about the member if different from the driver. It requires information about each trip, including dates, trip/job numbers, and medical provider details, ensuring each travel instance is accurately accounted for. A notable requirement is the signature of a physician or clinician for each service date, a step that verifies the medical necessity of the transportation. Before any reimbursement is issued, the form stipulates that each trip will be verified with the corresponding physician's office, emphasizing the company’s diligence in confirming the legitimacy of claims. Additionally, it highlights the necessity for separate forms for each individual transported and the declaration by the signer that all information provided is true and correct. Fulfilling these requirements is fundamental to facilitating a smooth reimbursement process.

QuestionAnswer
Form NameLogisticare Mileage Reimbursement
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslogisticare trip, logisticare reimbursement, logisticare mileage reimbursement, logisticare form

Form Preview Example

MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE FORM

Must be sent to: LogistiCare, Attn: Billing Dept, PO Box 248, Norton, VA 24273

DRIVER NAME:

 

 

 

RELATIONSHIP TO MEMBER:

 

 

DRIVER MAILING ADDRESS:

 

 

 

 

 

DRIVER PHONE #:

 

 

CITY/STATE/ZIP:

 

 

 

 

 

 

 

 

 

 

 

MEMBER NAME (If different from Driver):

 

 

 

 

MEMBER ID #:

 

 

IS TRIP A STANDING ORDER? Y N

IF YES, CIRCLE THE DAYS TRAVELED WEEKLY: S M T W T

F S

 

 

 

 

 

 

 

 

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 #:

 

 

 

 

 

 

 

 

 

 

*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.

Office Use Only: Do not write in this space.

 

 

 

Total mileage to be paid:_________________________

Total amount for this invoice:______________________

Batch #: ___________

Batch date:_______________

**PLEASE FILL OUT A SEPARATE FORM FOR EACH PERSON TRANSPORTED**

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

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We've used the hard work of our best developers to build the PDF editor you are about to work with. The software allows you to fill out the soonerride mileage reimbursement form document without any difficulty and don’t waste time. All you need to undertake is keep up with the following quick tips.

Step 1: The first step will be to hit the orange "Get Form Now" button.

Step 2: Now you are on the document editing page. You can edit, add information, highlight specific words or phrases, put crosses or checks, and add images.

Type in the appropriate information in every single area to get the PDF soonerride mileage reimbursement form

filling in logisticare trip log step 1

Type in the details in the Phone Name, Phone Name, Phone Name, Phone, Each date of service must have a, Office Use Only Do not write in, Total amount for this invoice, Batch, Batch date, PLEASE FILL OUT A SEPARATE FORM, and I hereby certify the information area.

Completing logisticare trip log stage 2

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Step 4: You can create duplicates of the file tostay clear of any type of possible future difficulties. Don't be concerned, we do not display or check your data.

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