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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. Signature of Individual Transportation Participant ITP Date All forms must be mailed to Logisticare ATTN Claims 12234 N* I -35 Suite 175 Austin TX 78753 Note Please retain a copy for your records. 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 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. 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. Signature of Individual Transportation Participant ITP Date All forms must be mailed to Logisticare ATTN Claims 12234 N* I -35 Suite 175 Austin TX 78753 Note Please retain a copy for your records. 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. .

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