Logisticare gas reimbursement schedule michigan 2011 form-2025

1. Click ‘Get Form’ to open the logisticare gas reimbursement schedule michigan 2011 form in the editor.
2. Begin by entering your name and mailing address in the designated fields. Ensure that your contact information is accurate for any follow-up.
3. Fill in the trip date and job number for each trip you are claiming reimbursement for. This helps track your mileage accurately.
4. Provide the member's name if it differs from yours, along with their ID number and relationship to you. This information is crucial for processing your claim.
5. List all medical providers' names and phone numbers associated with each trip. Make sure to include a physician or clinician signature for each date of service, as this is required for approval.
6. Calculate the total miles driven and enter this figure in the appropriate field, followed by the total amount you are claiming for reimbursement.
7. Finally, certify that all information provided is true by signing at the bottom of the form before submitting it through our platform.

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