Get Logisticare Kansas Mileage Reimbursement Form

This guide provides essential instructions on how to effectively fill out the Logisticare Kansas Mileage Reimbursement Form online. It aims to assist users in completing each section of the form accurately for timely reimbursement.

Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter your full name in the 'Driver Name' field.
3. Specify your relationship to the member in the designated section labeled 'Relationship to Member'.
4. Fill in your mailing address accurately in the 'Driver Mailing Address' field.
5. Provide your contact phone number in the 'Driver Phone #' section.
6. Input your city, state, and ZIP code in the relevant fields.
7. If the member is different from you, include their name in the 'Member Name' field.
8. Enter the member's ID number in the 'Member ID#' section.
9. Indicate whether this trip is a standing order by selecting 'Yes' or 'No'.
10. Record the trip date accurately.
11. Fill in the trip or job number as requested.
12. If the trip is a standing order, circle the days of the week traveled.
13. Provide the name and phone number of the medical provider in the appropriate section.
14. Ensure a physician or clinician signature is noted for each date of service for reimbursement approval.
15. List the total miles traveled for the trip.
16. Complete the additional physician/clinician names and phone numbers if more than one is needed.
17. Do not enter any information in the designated space marked 'DO NOT WRITE IN THIS SPACE'.
18. Calculate the total mileage to be paid and write it in the corresponding field.
19. Input the total amount for this invoice.
20. Specify the batch number and batch date as required.
21. Finally, certify the information by signing in the signature field.
22. After completing the form, save your changes, download the document, print it out, or share it as needed.

Start filling out your Logisticare Kansas Mileage Reimbursement Form online today!