Follow the steps to successfully complete the mileage log online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter your provider name in the designated field. Ensure that all information is accurate.
3. Fill in the date of service for which you are seeking reimbursement.
4. Input the service authorization number provided to you for the child's services.
5. Specify your official domicile - the location from which you operate.
6. Provide the child's last name as it appears in official records.
7. Enter the child's first name.
8. Select the discipline related to the service provided (e.g., physical therapy, occupational therapy).
9. Document the service you provided in the corresponding field.
10. Fill in the start address where the service started.
11. Indicate the destination address where the service was provided.
12. Select whether this was a round trip by marking the appropriate checkbox.
13. Calculate and enter the trip mileage for the service provided.
14. Total the miles traveled for the trip and enter it in the total miles field.
15. Read and certify that the information entered is accurate by checking the certification box.
16. Provide your signature to validate the form.
17. Enter the date you are submitting the form.
18. Once completed, save changes, download, print, or share the form as needed.

Complete your mileage log online now to ensure prompt reimbursement!