Gas Reimbursement Form Modivcare Each date of service must have a physician or clinician signature in order for reimbursement to be approved Note Each trip will be confirmed with the physician s office before payments will
ITP Gas Reimbursement Claim Form Example ITP Drivers Please note that the allowable mileage that may be claimed for reimbursement is preprinted on the form AFFIDAVIT This is Gas Reimbursement Payment Request Form Use one form per trip Form must be filled out completely to receive payment FOR MEMBER AND DRIVER TO COMPLETE Driver s First
Gas Reimbursement Form Modivcare
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Gas Reimbursement is a program to reimburse a member s friend neighbor or relative at a rate of 0 40 per mile from the member s residence to the Medicaid paid service and the return trip home What is the requirement for minors MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE For questions about your claim call 1 800 930 9060
You may fax this form to 1 866 528 0462 or email it to Virginia billingoperations ModivCare Note This form when completed will contain You may fax this form to 1 855 848 8636 or email it to LGTCReimbursement modivcare Note This form when completed will contain your personal Protected Health Information
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To enroll as a driver in the gas reimbursement program follow these steps Complete and sign the attached Driver Enrollment Form For help filling out the form call Modivcare at 1 866 726 You may fax this form to 1 866 528 0462 or email it to virginia billingoperations modivcare Note This form when completed will contain
ModivCare Claims Department 798 Park Avenue NW Norton VA 24273 Fax 866 528 0462 Gas Mileage Reimbursement Billing Inquiries 844 889 1942 DRIVER PHONE by submitting this South Carolina Mileage Reimbursement Trip Log Sur Carolina Formulario De Reembolso De Gasolina Must be sent to Enviar a LogistiCare Claims Department South Carolina Gas
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Each date of service must have a physician or clinician signature in order for reimbursement to be approved Note Each trip will be confirmed with the physician s office before payments will
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ITP Gas Reimbursement Claim Form Example ITP Drivers Please note that the allowable mileage that may be claimed for reimbursement is preprinted on the form AFFIDAVIT This is
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Gas Reimbursement Form Modivcare - You may fax this form to 1 866 528 0462 or email it to Virginia billingoperations ModivCare Note This form when completed will contain
