Trip logs: Fill out & sign online

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Click ‘Get Form’ to open the Reimbursement Trip Log in the editor.
Begin by filling in the Recipient Info section. Enter the First Name, Last Name, Address, City, State, Zip, Phone number, and Medicaid/CSHCN ID #.
In the Payment Info section, specify how you want your Re-Loadable Debit Card made payable and provide any additional required details.
For each trip leg, enter the Appointment Date and Time. Indicate whether it is a one-way or round trip and provide the Medical Provider's Name and Address.
Ensure that a healthcare provider signs each trip log entry. This can be done by having any enrolled Medicaid/CSHCN professional sign off on the service provided.
Review all entries for completeness. Incomplete forms cannot be processed, so double-check that all necessary information is filled out correctly.
Finally, keep a copy of your completed Trip Log for your records before submitting it via mail or fax as instructed.

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