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Soonerride mileage reimbursement form

Soonerride mileage reimbursement form 2026

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The document is a Mileage Reimbursement Form for SoonerRide Gas Reimbursement, intended for drivers to claim reimbursement for transportation to medical appointments. It requires details such as driver and member information, trip dates, medical provider details, and signatures from physicians or clinicians. The form must be submitted within 30 days of the appointment, and each trip will be verified with the physician's office before payment.

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Click ‘Get Form’ to open the soonerride mileage reimbursement form in the editor.
Begin by entering your DRIVER NAME, RELATIONSHIP TO MEMBER, and DRIVER MAILING ADDRESS in the designated fields. Ensure that your contact information is accurate for any follow-up.
Fill in your DRIVER PHONE # and CITY/STATE/ZIP. If the MEMBER NAME differs from yours, provide that information as well.
Indicate whether the trip is a standing order by selecting 'Y' for Yes or 'N' for No. If yes, circle the days traveled weekly.
List each trip date along with the Trip/Job # and Medical Provider Name & Phone #. Make sure to include a physician or clinician signature for each date of service.
Total up the miles driven for each trip and enter this information in the Total Miles field.
Finally, certify that all provided information is true by signing at the bottom of the form before submission.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (43 Votes)
2014	4.1 Satisfied (57 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long does ModivCare take to pay?

Payment will be mailed within thirty (30) business days of the ModivCare Claims Department receiving your completed reimbursement form. If you have any questions, please call ModivCare Claims Department at 1-800-930-9060.

What is the timeline for mileage reimbursement?

Timeline requirements Employees should document expenses within 60 days of the trip. Reimbursement should be provided within 30 days of expense submission.

How long does it take to get mileage reimbursement from ModivCare?

When ModivCare gets your form, they will call your doctors office to confirm you went to your appointment. Payment will be mailed to your driver within 15 days.

When should you get reimbursed for mileage?

If you drive your personal vehicle for business purposes, you will be eligible for mileage reimbursement from your employer. While no federal laws require employers to reimburse employee mileage, state laws sometimes require employees to provide mileage reimbursements.

How do I fill out a mileage reimbursement form?

Effective January 1, 2024, the mileage reimbursement rate changed from 65.5 cents to 67 cents per mile as directed by Internal Revenue Service (IRS). Effective January 1, 2024, the mileage reimbursement rate changed from 65.5 cents to 67 cents per mile as directed by Internal Revenue Service (IRS).

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How does ModivCare pay you for mileage reimbursement?

0:09 1:08 And try again. If you are within the correct range you will see the drivers name date and number ofMoreAnd try again. If you are within the correct range you will see the drivers name date and number of miles to submit for reimbursement. After clicking submit now you will see a confirmation.