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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How to fill out the TX LogistiCare ITP Service Record online
The TX LogistiCare ITP Service Record is a crucial document for individuals seeking reimbursement for transportation services related to Medicaid-covered health care. This guide provides clear, step-by-step instructions to help users accurately complete the form online.
Follow the steps to successfully complete the TX LogistiCare ITP Service Record online.
- Press the ‘Get Form’ button to access the TX LogistiCare ITP Service Record. This will enable you to open the form in your online editor.
- In the 'Client Name' field, enter the full name of the individual receiving the transportation services. This is an essential identification detail.
- Fill in the 'Client Telephone' field with the appropriate contact number, ensuring it is formatted correctly.
- Enter the 'Client Medicaid' number, which is necessary for processing the claim.
- In the 'ITP Name' field, write the name of the Individual Transportation Provider. This identifies who provided the transportation.
- Fill the 'ITP Telephone' field with the contact telephone number for the transportation provider.
- Provide the 'ITP MTI Number,' as this is a required identifier for reimbursement.
- For each trip listed (Trip #1 and Trip #2), fill in the 'From' and 'To' fields with the respective starting and ending locations.
- Input the mileage under 'Miles' for both trips to reflect the distance traveled.
- Enter the reimbursement 'Amount' for each trip, corresponding to the provided distance.
- Include the 'Authorization Number,' Appointment Date/Time, 'Total Miles,' and 'Total Amount' for each trip as required.
- In the health care provider sections, enter the Health Care Provider NPI, telephone number, and name. These fields ensure healthcare service accountability.
- The Health Care Provider must sign and date the certification statement affirming the service was provided.
- Complete the affidavit section with the signature of the Individual Transportation Participant and the date, confirming that all information is accurate.
- Finally, save your changes, and you may choose to download, print, or share the completed form.
Complete your TX LogistiCare ITP Service Record online today to ensure timely reimbursement for transportation services.
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