Follow the steps to accurately complete the Gas Mileage Reimbursement Log - MTM

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting your relationship to the recipient from the options provided: Self, Parent/Guardian, Licensed Foster Parent (include license number), or Other. Ensure that you select only one.
3. Indicate whether receipts are enclosed by selecting either 'YES' or 'NO'. Please remember not to staple or tape receipts to the trip log.
4. In the recipient information section, clearly fill in the required details including the recipient’s name, date of birth, and medical assistance number.
5. Provide the address, city, and phone number of the recipient, ensuring all information is accurate and complete.
6. Record the date of the appointment along with the start and end times in the specified format (MM/DD/YY).
7. Enter the starting address for the trip; if it is the home address, write 'HOME'.
8. Fill out the destination or facility information, including the name, address, and phone number of the provider.
9. Have a healthcare staff member sign and include their title, certifying that the patient was seen for a medical assistance billable service.
10. As the person completing the form, print your name, sign, and date the form to confirm the accuracy of all provided information.
11. Once all sections are completed, you can save your changes, download the form, print it, or share it as needed.

Ensure you complete your Gas Mileage Reimbursement Log - MTM online today for timely processing!