South Carolina Gas Mileage Reimbursement Trip Log Template printable pdf download

South Carolina Gas Mileage Reimbursement Trip Log Template

SOUTH CAROLINA GAS MILEAGE REIMBURSEMENT TRIP LOG

Must be sent to:

LogistiCare Claims Department

503 Oak Place, Suite 550

College Park, GA 30349

DRIVER NAME:

RELATIONSHIP TO MEMBER:

DRIVER MAILING ADDRESS:

DRIVER PHONE #:

CITY/STATE/ZIP:

MEMBER NAME (If different from Driver):

MEMBER ID#:

Trip Date

Trip/Job #

Medical Provider Name & Phone #

Physician/Clinician Signature*

Total Miles

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

*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 be made

Do not write in this space.

Total mileage to be paid:_________________________

Total amount for this invoice:______________________

Batch #: ___________

Batch date:_______________

I hereby certify the information contained herein is true, correct and accurate. Signature

Version 1.0 2011

South Carolina Gas Mileage Reimbursement Trip Log Template