Medicaid mileage reimbursement rate 2021-2025

1. Click ‘Get Form’ to open the Medicaid Mileage Reimbursement Rate 2021 form in the editor.
2. Begin by entering the Medicaid recipient’s name, date of birth, and Medicaid number at the top of the form.
3. Fill in the payment details, including where the payment should be sent and the mailing address.
4. Indicate if you have received any financial assistance for these trips by selecting 'YES' or 'NO' and providing details if applicable.
5. For each trip, enter the appointment details including departure and return cities, dates, times, and lodging information if necessary.
6. Complete the section for medical provider information, ensuring to include their name, address, phone number, and type of service provided.
7. Sign and date the form at the bottom to certify that all information is accurate before submitting it to the Department of Social Services.

Start filling out your Medicaid Mileage Reimbursement Rate 2021 form online for free today!