Get Me Modivcare Mileage Reimbursement Trip Log 2021-2025

Completing the ME Modivcare Mileage Reimbursement Trip Log is essential for ensuring that you receive timely reimbursement for your mileage expenses. This guide provides a straightforward approach to filling out the form accurately and efficiently.

Follow the steps to fill out the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the driver name and mailing address in the designated fields. Ensure that all information is accurate and up-to-date.
3. Enter the city, state, and zip code for the driver’s mailing address. This information is essential for correspondence regarding your reimbursement.
4. Provide the driver phone number in the specified field. This allows Modivcare to contact you if any questions arise regarding your submission.
5. Fill out the member name and member ID number if the member is different from the driver. Accurately input these details for proper tracking of the reimbursement.
6. Indicate the relationship of the driver to the member in the provided field. This helps clarify the connection for reimbursement purposes.
7. Input your driver's license number in the assigned section, affirming that you hold a current and valid unrestricted Maine driver’s license.
8. Review the certification statement carefully. By submitting the form, you affirm that the vehicle used has a valid inspection sticker and is properly registered and insured.
9. Enter the trip date for each service rendered. This is crucial for tracking and verification of your reimbursement claim.
10. Provide the Modivcare confirmation number and the medical provider's name and phone number for each trip to ensure proper documentation.
11. Each field related to service must have a physician or clinician signature. Make sure to obtain these signatures before submission.
12. Calculate the total miles driven for the trips included in the log and input this information in the designated field.
13. Review all filled details for accuracy and completeness before proceeding.
14. Once completed, save changes, download, print, or share the form as required.

Ensure timely reimbursement by completing and submitting your documents online.