Follow the steps to complete the MTM Reimbursement Trip Log online

1. Click the ‘Get Form’ button to obtain the MTM Reimbursement Trip Log and open it in your preferred document editor.
2. Fill out the member information section, which includes your first and last name, Medicaid number, address, phone number, city, state, date of birth, and payment details.
3. Contact MTM at 1-877-503-1261 on or before your medical appointment date to obtain a trip number. Write this number on the Trip Log.
4. Document each leg of your trip. If you have multiple appointments, enter each trip leg separately, e.g., home to first doctor, first doctor to second doctor, and so on.
5. Include the healthcare provider's name, appointment dates, appointment times, and the provider’s address for each leg of the trip.
6. Ensure that a healthcare professional signs the trip log. This can be any personnel at the facility, such as a nurse or therapist, as long as they provide their title.
7. Review the entire log for completeness. Incomplete forms cannot be processed, so ensure all necessary fields are filled in correctly.
8. Keep a copy of your completed Trip Log for your records before submitting.
9. Once completed, submit your Trip Log via mail, fax, or email to the provided MTM contact details.
10. You can save changes, download, print, or share the form as needed after completing it.

Start filling out your MTM Reimbursement Trip Log online today to ensure timely reimbursement.