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Get MI Logisticare Mileage Reimbursement Trip Log 2016

Partment 1640 Phoenix Boulevard, Suite 100 College Park, GA 30349 RELATIONSHIP TO MEMBER: DRIVER PHONE #: MEMBER ID#: Medical Provider Name & Phone # Physician/Clinician Signature* Total Miles Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: *Each date of service must have a physician or clinician signature in order for reimbursement to be approved. NOTE: Each trip will be confirmed with the physician’s office before payments will be.

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