Mileage Reimbursement Invoice Details

Logisticare is a transportation company that provides rides for people who need them. If you are a Logisticare client, you may be eligible for mileage reimbursement. The Logisticare Mileage Reimbursement Form is the document you need to submit in order to receive payment for your miles traveled. This form can be downloaded on the Logisticare website. In order to submit a claim, you will need to have your driver's license number, the dates of your trip, and the total mileage traveled. Be sure to keep track of your mileage, as it may be necessary to provide proof of travel later on.

Before you decide to complete logisticare mileage reimbursement, you will want to find out more in regards to the type of form you are going to work with.

QuestionAnswer
Form NameLogisticare Mileage Reimbursement
Form Length1 pages
Fillable?Yes
Fillable fields49
Avg. time to fill out10 min 7 sec
Other nameslogisticare transportation log sheets, logisticare gas reimbursement, logisticare trip log, logisticare forms

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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