Logisticare gas reimbursement schedule 2021-2026

1. Click ‘Get Form’ to open the logisticare gas reimbursement schedule 2021 in the editor.
2. Begin by entering your DRIVER NAME and DRIVER MAILING ADDRESS in the designated fields. Ensure that all information is accurate for seamless processing.
3. Fill in the CITY/STATE/ZIP, MEMBER NAME (if different from Driver), and DRIVER PHONE #. This information is crucial for identification and communication purposes.
4. Record the TRIP DATE and TRIP/ JOB #. These details help track each trip for reimbursement.
5. Input the MEDICAL PROVIDER NAME & PHONE #, along with the MEMBER ID#. This section verifies your association with the member receiving services.
6. List all relevant names and phone numbers of individuals involved in the trip. Each entry should be clear to avoid confusion during verification.
7. Ensure that a PHYSICIAN/CLINICIAN SIGNATURE is present for each date of service, as this is mandatory for reimbursement approval.
8. Finally, calculate and enter the TOTAL MILES and TOTAL AMOUNT FOR THIS INVOICE before signing at the bottom to certify accuracy.

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