Family Driver Reimbursement Form - Rtp Family Driver Program
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1
2FAMILY DRIVER REIMBURSEMENT FORM
MaineCare members may use this form to claim reimbursement at $0.21 per passenger mile effective 8/1/10 for driving to and from medical
appointments. Trip authorization number must be requested in advance. Call RTP between 8am & 4pm for numbers at 774-2666 Option 4.
STEP 1: GET THE TRIP NUMBER (S) BEFORE YOU GO
Write the trip number(s) and the date of your appointment in the space provided below. This form may be used for up to 4 round trips (for the same
rider) if traveling to the same medical office in the same calendar month. Trips to different medical offices or for more than one family member must
be on separate forms.
Trip # 1
[_________________]
Date [___/___/_______]
Trip # 2
[_________________]
Date [___/___/_______]
Trip # 3
[_________________]
Date [___/___/_______]
Trip # 4
[_________________]
Date [___/___/_______]
STEP 2: RECORD THE TRIP INFORMATION
Rider Name:
Last: ____________________________ First: _______________________
Trip Origin:
Street: ____________________________ City: _______________________
Trip Destination:
Street: ____________________________ City: _______________________
Medical Office:
Phys Name: _______________________ Facility: _____________________
Rider’s Maine Care Number: [_______________________________]
STEP 3 LOG VEHICLE ODOMETER READINGS FOR EACH TRIP
(ROUND TO THE NEAREST WHOLE MILE)
START
END
TOTAL MILES
Trip #1 FROM HOME TO MEDICAL OFFICE
________________________
_________________________
___________________
Trip #1 FROM MEDCIAL OFFICE TO HOME
________________________
_________________________
___________________
Trip #2 FROM HOME TO MEDICAL OFFICE
________________________
_________________________
___________________
Trip #2 FROM MEDCIAL OFFICE TO HOME
________________________
_________________________
___________________
Trip #3 FROM HOME TO MEDICAL OFFICE
________________________
_________________________
___________________
Trip #3 FROM MEDCIAL OFFICE TO HOME
________________________
_________________________
___________________
Trip #4 FROM HOME TO MEDICAL OFFICE
________________________
_________________________
___________________
Trip #4 FROM MEDCIAL OFFICE TO HOME
________________________
_________________________
___________________
STEP 4: SPECIFY PAYMENT INSTRUCTIONS
A check will be sent to the Maine Care member, legal guardian, or the family member/friend who drove the vehicle.
Vendor No:
Make Check Payable to:
F
‘
Account
Amount
6620.02
Last Name: ___________________________ First Name: _______________________
‘
Check if new address
Street Address: ___________________________________________________________
City: ____________________________ State: ______________ Zip Code: ______________
(OVER)
Driver’s Phone #: (______) ________________
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