Medicaid Transportation Mileage Reimbursement Claim Form

Claimant Full Name

First NameMiddle NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Relationship to Medicaid Recipient

Preferred Contact Method

Medicaid recipient full name

First NameMiddle NameLast Name

Medicaid recipient date of birth

Date

Medicaid program or member type

Healthcare provider or facility visited

Relationship of claimant to recipient

Date of Travel

Date

Appointment or Service Date

Date

Pickup Location / Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Drop-off Location / Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Trip Type

Transportation Method Used

Purpose of Trip

Was This Trip for a Medically Necessary Appointment?

Total miles driven for this trip

How was mileage calculated?

Other

Start odometer reading

End odometer reading

Number of passengers for this trip

Reimbursement amount requested

Appointment Confirmation

Trip Log or Supporting Receipt

Additional Notes or Explanation

Preferred reimbursement delivery method

Mailing instructions

Certification

Claimant Signature

Date Signed

Date

Medicaid Transportation Mileage Reimbursement Claim Form

Claimant Information

Recipient and Eligibility Details

Trip Information

Mileage and Reimbursement Details

Supporting Documentation

Payment and Reimbursement Preference

Certification and Submission