PUBLIC TRANSIT REIMBURSEMENT REQUEST FORM - metroplus: Fill out & sign online

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Click ‘Get Form’ to open the PUBLIC TRANSIT REIMBURSEMENT REQUEST FORM in our editor.
Begin by entering the Provider Name and Address. Ensure that all details are accurate for proper identification.
Fill in the Designated Provider Contact's name, title, and telephone number. This contact will handle all matters related to public transit coverage.
Sign and date the form in the designated fields to validate your request.
Input the number of MetroCards distributed at each price point. Make sure to calculate the total amounts accurately.
Verify that the total amount of reimbursement request matches the total dollar value of public transit fare distributed as recorded on the attached log.
Once completed, save your document and attach it along with the Public Transit Fare Distribution Log before submitting it to MetroPlus Health Plan.

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