Modivcare Mileage Reimbursement Form Instructions
This form is essential for drivers seeking mileage reimbursement for services related to medical appointments. It collects necessary information about the driver, the trip, and the medical provider. Complete and submit this form within 30 days to ensure prompt reimbursement.
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How do I fill this out?
To fill out this form, gather all the necessary information beforehand such as the driver and member details. Ensure that each trip date has a physician or clinician signature for approval. Review all entries carefully before submission.
How to fill out the Modivcare Mileage Reimbursement Form Instructions?
1
Collect all required information about the driver and member.
2
Fill in the trip details including date, job number, and medical provider.
3
Ensure that each entry has the necessary signature from a physician or clinician.
4
Calculate the total miles traveled accurately.
5
Submit the completed form either via fax or email within 30 days.
Who needs the Modivcare Mileage Reimbursement Form Instructions?
1
Drivers working with Modivcare who provide transportation for medical appointments.
2
Members receiving services who need to reimburse their drivers for mileage.
3
Healthcare providers requiring confirmation of transportation for patient visits.
4
Billing departments managing claims for mileage reimbursement.
5
Patients seeking assistance with transport costs associated with their medical needs.
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What are the instructions for submitting this form?
Submit the completed Modivcare Mileage Reimbursement Form via fax at 1-855-848-8636 or email it to LGTCReimbursement@modivcare.com. Ensure that you send your completed form within 30 days of the trip date to avoid denial of reimbursement. For physical submissions, mail the form to Sooner Ride Mileage Reimbursement, 2552 West Erie Drive, Suite 101, Tempe, AZ 85282-3100.
What are the important dates for this form in 2024 and 2025?
Important dates for submitting this form include any medical appointments as they occur throughout the year. For the 2024 calendar, submissions should be made within 30 days of your scheduled appointments. Plan ahead to ensure compliance with submission deadlines.
What is the purpose of this form?
The purpose of this form is to facilitate reimbursement for mileage incurred by drivers transporting members to medical appointments. It ensures that both the driver and the member can document and verify transportation services provided. Completing this form accurately is crucial for timely reimbursement and compliance with Modivcare’s policies.
Tell me about this form and its components and fields line-by-line.
- 1. Driver Name: Enter the full name of the driver providing the transportation.
- 2. Driver Mailing Address: Input the driver's complete mailing address.
- 3. Driver Phone: Provide a contact number for the driver.
- 4. Member Name: Enter the name of the member, if different from the driver.
- 5. Member ID: Record the member's identification number.
- 6. Trip Date: Indicate the date of the trip being reimbursed.
- 7. Total Miles: Calculate and enter the total miles traveled.
- 8. Physician Signature: Signature from the physician or clinician to authorize reimbursement.
What happens if I fail to submit this form?
Failing to submit this form may result in the denial of reimbursement claims for incurred mileage. It is essential to adhere to the submission deadline of 30 days post-appointment. Missing the deadline could lead to uncompensated travel expenses.
- Denial of Payment: If the form is not submitted on time, reimbursement requests may be denied.
- Increased Out-of-Pocket Costs: Delays or failures in submission can lead to higher transportation costs for members.
- Loss of Trust: Frequent issues with submission may erode trust between drivers and members.
How do I know when to use this form?
- 1. Transporting Members: To document trips where drivers are transporting members to medical visits.
- 2. Claiming Mileage for Reimbursement: For members needing reimbursement for transportation expenses.
- 3. Coordinating with Healthcare Providers: To verify transportation needs and associated costs with healthcare providers.
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