Follow the steps to complete your mileage reimbursement trip log and claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the member name in the designated field to identify the individual eligible for reimbursement.
3. Fill in the Medicaid ID number, which is essential for processing the claim.
4. If the driver is different from the member, provide the driver's name and mailing address to ensure proper identification.
5. Input the driver phone number for contact purposes regarding the claim.
6. The driver must sign in the designated area, confirming their role in the trip.
7. Indicate the city, state, and zip code of the driver's residence.
8. For repetitive trips (such as cancer treatment or dialysis), provide the date range next to the physician/clinician signature block.
9. List each trip date along with the confirmation number and medical provider's name, address, and phone number.
10. Include the physician/clinician signature for each trip indicated for reimbursement.
11. Specify if each trip is repetitive by selecting 'Yes' or 'No' in the provided field.
12. Calculate and enter the total miles traveled for all trips listed on the form.
13. Ensure that dates do not exceed one month for mileage claims.
14. Read and agree to the mileage reimbursement policy by checking the box provided.
15. Sign and date the form to certify that all provided information is true and accurate.
16. After completing the form, save any changes you've made, download a copy for your records, and prepare to submit it to TMS Management Group.

Submit your completed IA TMS 470-0386 form online today for efficient processing and reimbursement.