Virginia logisticare form 2026

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Click ‘Get Form’ to open the Virginia Logisticare form in the editor.
Begin by entering your Transportation Provider Name, Contact Person, and Phone Number in the designated fields at the top of the form.
Fill in the Week Ending Date to specify the period for which you are reporting transportation services.
In the Totals for Transportation section, input the number of trips for each category: Ambulatory Trips, Wheelchair Trips, Stretcher Van Trips, and Ambulance Trips. Ensure that you enter accurate figures.
Calculate and enter the total amounts for each type of trip next to their respective categories.
For office use only, leave space for Check Run details, Week Beginning and Ending dates, Total Trips Paid and Denied, Clerk's Initials, Total Amount Paid, Date Invoice Received, LogistiCare Invoice No., and LogistiCare Batch No. as these will be filled out later.

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