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Wv dhhr mileage reimbursement 2026

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The document is a supplemental application form for the Non-Emergency Medical Transportation (NEMT) Reimbursement Program by the West Virginia Department of Health and Human Resources. It outlines the process for requesting reimbursement for transportation to medical appointments, including requirements for submitting trip details, verification from medical providers, and necessary documentation for mileage, lodging, and meal expenses.

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Click ‘Get Form’ to open the wv dhhr mileage reimbursement form in the editor.
Begin by entering your name and address as the Driver in the designated section. Ensure accuracy to avoid payment issues.
Fill in the details for each trip, including the Patient’s Name, Purpose of Visit, Date and Time of Appointment, and Medical Provider's information.
Indicate your mode of transportation (e.g., Private Vehicle, Taxi) and provide your SSN or Tax ID number.
Complete the cost sections for Mileage, Parking, Tolls, Lodging, and Meals. Attach any necessary receipts for verification.
Review all entries for accuracy before submitting. Once satisfied, save or export your completed form directly from our platform.

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