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MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE FORM Must be sent to LogistiCare Inc Missouri NEMT Billing Department 503 Oak Place Ste. 550 Atlanta GA 30349 NAME RELATIONSHIP TO PARTICIPANT DRIVER MAILING ADDRESS DRIVER PHONE CITY/STATE/ZIP PARTICIPANT NAME If different from Driver IS TRIP A STANDING ORDER Trip Date Trip/Job Y N PARTICIPANT ID IF YES CIRCLE THE DAYS TRAVELED WEEKLY S M T W T F S Medical Provider Name Phone Name Physician/Clinician Signature Total Miles Phone Each date of service must have a clinical signature in order for reimbursement to be approved* NOTE Each trip will be confirmed with the physician s office before payments will be made. This form must be received within 30 days of your appointment. Do not write in this space. Total mileage to be paid Total amount for this invoice Batch Batch date PLEASE FILL OUT A SEPARATE FORM FOR EACH PERSON TRANSPORTED I hereby certify the information contained herein is true correct and accurate. 550 Atlanta GA 30349 NAME RELATIONSHIP TO PARTICIPANT DRIVER MAILING ADDRESS DRIVER PHONE CITY/STATE/ZIP PARTICIPANT NAME If different from Driver IS TRIP A STANDING ORDER Trip Date Trip/Job Y N PARTICIPANT ID IF YES CIRCLE THE DAYS TRAVELED WEEKLY S M T W T F S Medical Provider Name Phone Name Physician/Clinician Signature Total Miles Phone Each date of service must have a clinical signature in order for reimbursement to be approved* NOTE Each trip will be confirmed with the physician s office before payments will be made. This form must be received within 30 days of your appointment. Do not write in this space. Total mileage to be paid Total amount for this invoice Batch Batch date PLEASE FILL OUT A SEPARATE FORM FOR EACH PERSON TRANSPORTED I hereby certify the information contained herein is true correct and accurate.

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