Get Az Soonerride Mileage Reimbursement Form 2017-2026

The AZ SoonerRide Mileage Reimbursement Form is an essential document for users seeking reimbursement for transportation expenses related to medical appointments. This guide will walk you through the process of completing the form online with clarity and precision.

Follow the steps to complete the AZ SoonerRide Mileage Reimbursement Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the driver's name in the designated field, ensuring accurate spelling as this will identify you as the submitter of the reimbursement request.
3. Indicate your relationship to the member receiving the transportation service by selecting from the appropriate options provided.
4. Provide your mailing address in the field labeled 'Driver Mailing Address'. Be sure to include all necessary details such as street address, city, state, and ZIP code.
5. Enter your phone number in the 'Driver Phone #' section, as this may be needed for follow-up communication.
6. If the member's name differs from the driver's name, fill in the 'Member Name' field to clarify whose transportation is being reimbursed.
7. Answer the question about whether the trip is a standing order by selecting 'Y' for yes or 'N' for no.
8. If you selected yes, indicate the days traveled weekly by circling the appropriate days on the form.
9. Input the Member ID number, as this is necessary for verifying the member's eligibility.
10. Carefully log the trip date, job number, and the name and phone number of the medical provider associated with the trip.
11. Obtain the physician or clinician signature for each trip date in the designated section to ensure payment approval.
12. Document the total miles traveled for the trip, summarizing the distance accurately.
13. Once all fields are filled out correctly, review the information for accuracy before finalizing your form.
14. Save changes, download a copy for your records, print the form, or share it as needed to submit it to the LogistiCare Claims Department.

Start completing your AZ SoonerRide Mileage Reimbursement Form online today!