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Louisiana mileage form 2026
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- 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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Related links
STATE OF LOUISIANA. DAILY VEHICLE LOG. Gallons. Date Trip Ending Reading Trip Mileage of Fuel. VIN. License Plate. Month. Year. Unit #. Model. Model Year. Notes.Read more
Your quote wont embody your mileage, so we recommend doing the maths yourself to get a greater idea of what youll end up spending primarily based on how far
Each trip should include the date, the ending odometer reading, the beginning and ending points of the trip, the purpose of the trip, and the drivers initials.Read more