Fillable Nyc Early Intervention Program Mileage Reimbursement Form printable pdf download

Nyc Early Intervention Program Mileage Reimbursement Form

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NYC Early Intervention Program Mileage Reimbursement Form

Instructions: The NYC Early Intervention (EI) provider agency Transportation Coordinator (TC) must complete the

Mileage Reimbursement Form with parents/caregivers monthly when mileage reimbursement is authorized as part of the

child’s Individualized Family Service Plan (IFSP). The TC will then send the completed form and accompanying

documentation for tolls and/or parking to the EI Fiscal Management Unit (EIFM) using HCS Secure File transfer to

username : Hinrjk02 within seven (7) calendar days after the end of each calendar month.

Child’s Name:(Last)

(First)

Date of Birth (DOB):

EI #:

IFSP Period: Start:

End:

Service Authorization Number:

Parent’s Full Name:

Phone:

Parent’s Address:

City:

State:

Zip Code:

Name of IFSP Authorized Destination (EI Provider):

Destination Address:

City:

State:

Zip Code:

I certify that the expenses itemized below are for the purposes of transporting my child to and from facility-based services

authorized on his/her IFSP. I understand that I will not be reimbursed for tolls and parking unless I submit receipts as part

of this request. I will receive a maximum reimbursement of $100.00 per day in the form of a check mailed to me by the

NYC Department of Health and Mental Hygiene (NYC DOHMH) no more than three (3) weeks from the date that the

Mileage Reimbursement Form is received by the EIFM. I hold the NYC DOHMH harmless in the case of accidental

death, injury or property damage associated with the use of my motor vehicle.

Date Traveled

Total Miles

Rate per Mile

Total Expenses

$ 0.575 (2)

MM/DD/YYYY

Round Trip (1)

(1) x (2)

$ 0.575 (2)

$ 0.575(2)

$ 0.575 (2)

Sub-Total

Tolls (if applicable)

Parking (if applicable)

Grand Total

Name (Parent): _________________________________Signature:_____________________Date:

____ / ____ / ____

I certify that the above EI child received services at the program on the above dates.

Name (TC): ___________________________________Signature:_____________________Date:

____ / ____ / ____

NYC EIP Mileage Reimbursement Form 3 2015

Nyc Early Intervention Program Mileage Reimbursement Form

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