Logisticare mileage reimbursement form 2026

1. Click ‘Get Form’ to open the logisticare mileage reimbursement form in the editor.
2. Begin by entering your name in the 'DRIVER NAME' field, followed by your relationship to the member and your mailing address. Ensure that your contact number is accurate in the 'DRIVER PHONE #' section.
3. Fill in the 'MEMBER NAME' if it differs from yours, and indicate whether the trip is a standing order by selecting 'Y' or 'N'.
4. Record the trip date and job number, then provide the member ID number. If applicable, circle the days traveled during that week.
5. List the medical provider's name and phone number, ensuring you obtain a physician or clinician signature for each date of service to facilitate reimbursement approval.
6. Calculate and enter the total miles driven and any additional details required for processing. Remember to sign at the bottom certifying that all information is accurate.

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