Plan, Inc. Finance Department 160 Water Street 4th Floor New York, NY 10038 Provider Name (Requestor): Provider Address: Address Line 1 Address Line 2 Designated Provider Contact 1 Name and Title Telephone Numb.
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How to fill out the MetroPlus Health Plan MBR 22.325 online
Filling out the MetroPlus Health Plan MBR 22.325 online can streamline the public transit reimbursement process. This guide will walk you through each section of the form to ensure you provide the necessary information accurately.
Follow the steps to complete your MBR 22.325 form
- Click ‘Get Form’ button to obtain the MetroPlus Health Plan MBR 22.325 form and open it in the editor.
- Begin by entering the provider name in the designated field. This should be the name of the requesting provider.
- Fill out the provider address. Ensure to complete both Address Line 1 and Address Line 2 for accurate delivery.
- In the designated provider contact section, enter the name and title of the person authorized to handle reimbursement matters.
- Provide the telephone number of the designated provider contact to ensure direct communication if needed.
- The designated provider contact must sign the form to confirm authorization. Ensure that the signature is legible.
- Enter the date on which the form is being completed.
- List the number of MetroCards distributed at the given rates ($2.20, $2.25, $4.50) in the respective fields.
- Calculate the total amount of cash distributed and enter it in the specified field. Double-check calculations to ensure accuracy.
- The total amount of reimbursement request must equal the total dollar value of public transit fares distributed. Confirm consistency with the attached Public Transit Fare Distribution Log.
- Once all fields are completed, you may save your changes, download the form, print it out, or share it as needed.
Complete your MetroPlus Health Plan MBR 22.325 form online for an efficient reimbursement process.
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