Mileage Reimbursement Verification Form Standing Order 2025

1. Click ‘Get Form’ to open the Mileage Reimbursement Verification Form Standing Order in the editor.
2. Begin by entering your personal information in the 'Member Information' section. Fill in your first name, last name, phone number, date of birth, Health First Colorado ID number, and email address.
3. In the 'Reason for standing order' section, select the appropriate order purpose such as Dialysis, Chemo, or other services. If applicable, provide additional details in the 'Other' field.
4. Complete the 'Pickup Information' by providing your street address, city/state/zip code, and any pickup notes that may assist your driver.
5. Indicate whether you will be accompanied by an escort or personal care attendant and provide their contact phone number if necessary.
6. Fill out the 'Dropoff Information' including the medical provider's name and confirm if you have access to a working vehicle. If yes, specify your preferred transportation provider.
7. Set your appointment details by entering start time, end time, start date, and any end date if applicable. Mark the days of your appointments in the schedule section.
8. Finally, review all provided information for accuracy before signing under 'Agreement & Signature'. Ensure to print your name and title or NPI before submitting.

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