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How to use or fill out Louisiana Mileage Form with DocHub
- Click ‘Get Form’ to open the Louisiana Mileage Reimbursement Trip Log in our editor.
- Begin by entering your DRIVER NAME, RELATIONSHIP TO MEMBER, and DRIVER MAILING ADDRESS in the designated fields. Ensure all information is accurate for processing.
- Fill in your DRIVER PHONE # and CITY/STATE/ZIP. If the MEMBER NAME differs from the driver, include that as well.
- Record the TRIP DATE and TRIP/JOB #. This information is crucial for tracking your mileage claims.
- Input the MEMBER ID# and MEDICAL PROVIDER NAME & PHONE #. This connects your trip to the appropriate medical services.
- List each physician or clinician's name and phone number who will sign off on the trip for reimbursement approval.
- Document TOTAL MILES traveled during the trip and ensure you have a signature from a physician or clinician for each date of service.
- Finally, certify that all information is true by signing at the bottom of the form before submitting it to LogistiCare Claims Department.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4.8 Satisfied (62 Votes) |
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