Family Driver Reimbursement Form - Rtp Family Driver Program (Page 2 of 2) in pdf

Family Driver Reimbursement Form - Rtp Family Driver Program Page 2

STEP 5: HAVE YOUR TRIP(S) VERIFIED BY THE MEDICAL OFFICE

Medical Office Manager:

Please certify that the rider named in step 2 was seen at this office for medical

services on the dates listed on the front in step one. This should be completed

after all appointments listed on the front.

________________________________________________

__________________________

Medical Office Signature or Stamp

Date Verified

STEP 6: CLIENT OR GUARDIAN SIGN AND DATE CERTIFCATION

Certification: I certify that I, (or the named rider), am currently eligible for Maine Care benefits and have no other means

to cover the transportation. I herby request travel reimbursement for the trip mileage logged in step 3 of this form. To the

best of my knowledge, all claim information provided is correct. Mileage was recorded at times only while I, (or the named

rider), was riding directly to or from the medical office.

I understand that if multiple MaineCare riders are receiving

transportation in the same vehicle at the same time that reimbursement can be made for only one.

_______________________________________________

_________________________

Signature of Client, Parent or Guardian

Date Certified

STEP 7: MAIL FORMS WEEKLY

Please submit completed forms to RTP weekly. All forms for a calendar month should be turned in by the first

week of the next month. If multiple months worth of forms are submitted at one time, it may take longer to process

and receive reimbursement. Thank you for your cooperation.

MAIL TO

RTP Family Driver Program

127 Saint John Street

Portland, ME 04102-3072

Before mailing the claim, can you answer yes to the following?

1. Was (were) the trip authorization number(s) obtained in advance?

2. Is all information provided on this form legible and complete?

3. Are the odometer readings rounded to the nearest whole mile?

4. Is the payment information in step 4 complete, clear and correct?

5. Has the medical office verified the trips(s) and dates?

6. Has the certification been signed and dated?

Missing information, incorrect dates and/or unsigned forms will be returned for corrections prior to reimbursements being

made.

If you have questions or need reimbursement claim forms, please call 774-2666 Option 4

Family Driver Reimbursement Form - Rtp Family Driver Program Page 2