Member Mileage Reimbursement Form
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1Member Mileage Reimbursement Form
Member Information
Member Name (first & last):
Address:
City, State ZIP:
Telephone:
Medicaid ID Number:
Driver Information (If not the member)
Vendor? Check here
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Payee Name (if different from member):
Address:
City, State ZIP:
Telephone:
Relationship to Member (circle one):
Self / Parent or Guardian / Household Member / Other (specify): ____________________
Trip Information
Trip Date:
Starting Location (full address required):
Ending Location (full address required):
Name of Provider:
Total Miles:
One way
Round trip
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Other Fees Incurred (tolls, parking fee, bus fee):
Note: Receipts are required for any fee incurred over $3.00
Provider Section (Please have your provider fill this section out)
Provider Name (please print):
Specialty:
Date of Appointment:
“I certify that New Hampshire Medicaid services were rendered for the recipient listed above on the trip date above.”
Provider Signature:
Today’s Date:
Please submit this form and any receipts via mail or fax to:
New Hampshire Mileage Reimbursement Team
2500 Abbott Place
St. Louis, MO 63143
Fax: 314-951-7475
Any reimbursement forms received after 90 days of the scheduled trip will not be eligible for mileage reimbursement.
For Meridian Transportation Vendor Use Only
Receipts Verified?:
Yes
No
Amount to be Reimbursed: $
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Please contact Meridian Member Services at 855-291-5221 if you have questions about this form.
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