Get Mileage Reimbursement Form - Logisticare

Filling out the Mileage Reimbursement Form - LogistiCare online can be straightforward with the right guidance. This guide provides clear instructions to help you complete the form efficiently and accurately.

Follow the steps to complete your Mileage Reimbursement Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by entering your details in the 'Driver Name' field. It is essential to provide the full name for proper identification.
3. In the 'Relationship to Member' section, specify your relationship to the member for whom the trip is being recorded. This helps clarify your connection.
4. Complete the 'Driver Mailing Address' with your current mailing address, ensuring it is accurate for correspondence purposes.
5. Enter your phone number in the 'Driver Phone #' field. This contact information is crucial for any follow-up regarding the reimbursement.
6. Input the relevant details for 'City/State/Zip' to further validate your mailing address.
7. If the member name differs from yours, fill in the 'Member Name' field accordingly. Accurate identification aids in processing.
8. Record the 'Trip Date' accurately, denoting the date when the trip occurred.
9. Fill in the 'Trip #' assigned for this journey. This number helps track your request more efficiently.
10. Provide the 'Member ID#' associated with the individual for whom the trip was made, ensuring proper billing and tracking.
11. Enter the 'Healthcare Provider Name & Phone #' in the designated area. This helps validate the service provided during the trip.
12. Specify 'To Address' and 'From Address' fields with the accurate starting and ending addresses of the trip to help in mileage calculation.
13. Gather signatures from the physician or clinician for each date of service in the 'Physician/Clinician Signature' section. This is mandatory for payment processing.
14. In the 'Total mileage to be paid' section, enter the total mileage for the trip. This will determine the reimbursement amount.
15. Complete the 'Total amount for this invoice' with the calculated reimbursement amount based on the mileage you've logged.
16. Fill in the 'Batch #' and 'Batch date' as necessary for tracking and processing your reimbursement request.
17. Lastly, provide your 'Signature' in the 'Member’s Signature' field, certifying that all information provided is true and accurate.
18. After finishing all sections, ensure to save your changes. You can also download, print, or share the filled form online as needed.

Start completing your Mileage Reimbursement Form online today to ensure prompt processing of your request.