Appointment Verification
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1
2APPOINTMENT VERIFICATION
CLIENT NAME:
PHONE:
Please complete and return by mail
HOME ADDRESS:
City
Zip
OHP+ Number:
DATE OF BIRTH:
DATE of
TIME of
REASON
PHYSICIAN or
PHYSICIAN
PHYSICAN OR CLINIC
MILEAGE to
appointment
appointment
for
CLINIC NAME &
or CLINIC
SIGNATURE AND STAMP
be c
alculated by
appointment
ADDRESS
PHONE
RideLine using
mapping
software
Check one:
Check one:
Physician / Office Rep Signature date
AM
One way
Clinic/ Physician Stamp Here
PM
Round trip
Check one:
Check one:
Physician / Office Rep Signature date
AM
One way
Clinic/ Physician Stamp Here
PM
Round trip
Check one:
Check one:
Physician / Office Rep Signature date
AM
One way
Clinic/ Physician Stamp Here
PM
Round trip
To be completed by RideLine:
MILEAGE to be calculated by RideLine using mapping software
Total mileage both pages ________
Please complete one section for each of your appointments. Have each appointment entry signed by your healthcare provider. Return the
form with your healthcare providers’ original signatures (no copies or faxes). To receive travel reimbursement, we must receive this form
CASCADES WEST RIDELINE
within 45 days of your appointment. Trips older than 45 days are not eligible for payment. Mail form to:
1400 Queen Ave SE Suite 205 Albany, OR 97322 541-924-8738
For lodging reimbursement, please attach your original lodging receipt to this form.
Client/Guardian Signature:
Phone:
Date:
Mailing Address
:
City:
Zip:
(if different from home address)
By signing this form, you are verifying the information provided is true.
PAYEE NAME:
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