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  • Tx Logisticare Itp Service Record

Get Tx Logisticare Itp Service Record

ITP Service Record Claim Form Client Name Client Telephone Client Medicaid ITP Name ITP Telephone ITP MTI Number Trip 1 From To Miles Amount Authorization Number Appointment Date/Time Total Miles Total Amount Health Care Provider NPI I certify that this patient was seen for a Medicaid/CSHCN covered health-care service. Signature Title of Health-care Provider Date Signed Trip 2 ITP Drivers Please note that the allowable mileage that may be claimed for reimbursement is preprinted on the form* AFFIDAVIT This is to certify that the foregoing information is true accurate and complete. I understand that payment of this claim is from Federal and State funds and that any falsification or concealment of a material fact may be prosecuted under Federal and State laws. I hereby my knowledge and belief* I attest that I have complied with all of the provisions of the Individual Transportation Participant Agreement when providing the transportation services for which I am seeking reimbursement. Signa....

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Related content

LogistiCare - Inspector General - Texas.gov
Aug 22, 2019 - were supported by the required ITP Service Record. The OIG Audit Division...
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232