Logisticare Mileage Reimbursement PDF 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?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

How to Edit Logisticare Mileage Reimbursement Online for Free

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

Step 3: Once you click on the Done button, the finished file is readily exportable to each of your gadgets. Alternatively, you can easily deliver it using email.

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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