Med Escort Mileage - Consumer Direct Care Network
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1
2Medical Escort Mileage
Service Code: CFCA0080
Round mileage to the nearest mile.
Medical Escort Records are due every week. They are due by the Monday following the end of the week by Midnight. You may fax, drop
off, or email them. Mail is discouraged as it can not guarantee timely pay. Due to the timing of the payroll cycle, late forms will result in late
pay. Medical Escort Records must be signed AFTER all work is completed. Advance forms will not be accepted.
Escort time is above and beyond time authorized on the MPQH services profile. All miles must be requested through Medicaid
Transportation by calling 1-800-292-7114. For approved trips, if miles are not reimbursed through the Medicaid Transportation program,
they can be requested to be paid by Consumer Direct by submitting your mileage request below. All Medical Escort trips must be verified by
the physician or an authorized representative of the medical office.
Employee Name (Please Print)
Employee ID
Member Name (Please Print)
Member ID
Odo Start (last 3):
Odo End (last 3):
Specific Location of Appointment:
Service Date (MM/DD/YY)
Mileage:
/
/
1
Med Trans Ref#:
Name of Health Care Provider:
Medical Office Rep. Signature:
By signing, I verify this
office is a Medicaid
Provider and the Member
attended this appointment.
Odo Start (last 3):
Odo End (last 3):
Specific Location of Appointment:
Service Date (MM/DD/YY)
Mileage:
/
/
2
By signing, I verify this
Med Trans Ref#:
Name of Health Care Provider:
Medical Office Rep. Signature:
office is a Medicaid
Provider and the Member
attended this appointment.
Odo Start (last 3):
Odo End (last 3):
Specific Location of Appointment:
Service Date (MM/DD/YY)
Mileage:
/
/
3
By signing, I verify this
Med Trans Ref#:
Name of Health Care Provider:
Medical Office Rep. Signature:
office is a Medicaid
Provider and the Member
attended this appointment.
Odo Start (last 3):
Odo End (last 3):
Specific Location of Appointment:
Service Date (MM/DD/YY)
Mileage:
/
/
4
Med Trans Ref#:
Name of Health Care Provider:
Medical Office Rep. Signature:
By signing, I verify this
office is a Medicaid
Provider and the Member
attended this appointment.
Service Date (MM/DD/YY)
Odo Start (last 3):
Odo End (last 3):
Mileage:
Specific Location of Appointment:
/
/
5
Med Trans Ref#:
Name of Health Care Provider:
Medical Office Rep. Signature:
By signing, I verify this
office is a Medicaid
Provider and the Member
attended this appointment.
I certify that the services indicated
Employee Signature
Date (MM/DD/YY)
about were provided to the Member
/
/
by the Employee as recorded.
Services were provided by the
Member/PR Signature
Date (MM/DD/YY)
nearest Medicaid Provider. The
/
/
Member was NOT in a hospital,
nursing home, or institution. False
Provider Representative Signature
Date (MM/DD/YY)
information or misrepresentation
constitutes Medicaid fraud and may
/
/
result in dismissal from the program
and/or criminal prosecution.
Drop Off: 3301 Great Northern Ave. Ste 203 Missoula, MT 59808
41424
Fax: 1-855-486-7246
Rev. 12/23/16
Email:
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Parent category: Medical