Secure Transportation New Mexico Reimbursement Form
This file is a reimbursement log form for Secure Transportation services in New Mexico. It is used to log trip details including driver and member information, trip dates, distances, and medical providers. Providers' signatures are required for validation.
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How do I fill this out?
Begin by filling out the driver's information, including name, relationship to member, and contact details. Next, record the member's ID, name, and trip details including date, number, and mileage. Ensure each trip entry is signed by the medical provider to complete the log.
How to fill out the Secure Transportation New Mexico Reimbursement Form?
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1. Fill out the driver's information: name, relationship to member, address, and contact details.
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2. Enter the member's ID and name (if different from the driver).
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3. Record trip details: date, number, medical provider's name, and phone number.
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4. Have the provider sign each trip entry.
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5. Submit the form to Secure Transportation within 90 days of the service date.
Who needs the Secure Transportation New Mexico Reimbursement Form?
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1. Secure Transportation drivers needing reimbursement for service trips.
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2. Members or their representatives seeking mileage reimbursement.
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3. Medical providers verifying trip details for reimbursement purposes.
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4. Administrative staff managing trip reimbursements.
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5. Caregivers or family members assisting with reimbursement paperwork.
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1. Upload your PDF to PrintFriendly.
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What are the instructions for submitting this form?
Submit the completed form by fax to (562) 236-4143, email to MREncounters@securetransportation.com, or mail to Secure Transportation, Attn: Mileage Reimbursement, 12800 Center Court Drive S, Suite 120, Cerritos, CA 90703. Ensure all required fields are filled, and the form is submitted within 90 days of the service date for processing.
What are the important dates for this form in 2024 and 2025?
Forms must be submitted within 90 days of the service date. For 2024 and 2025, please ensure all forms are completed and submitted as early as possible within the given timeframe to avoid delays.
What is the purpose of this form?
The purpose of the Secure Transportation New Mexico Reimbursement Log is to facilitate the reimbursement process for transportation services provided to members. The form helps in maintaining accurate records of trips, distances traveled, and the medical providers involved. By ensuring each trip is properly documented and signed by the provider, Secure Transportation can process reimbursements efficiently and accurately.
Tell me about this form and its components and fields line-by-line.
- 1. Driver Name: The name of the driver providing transportation services.
- 2. Relationship to Member: The driver's relationship to the member, e.g., self, family member, caregiver.
- 3. Driver Mailing Address: The driver's residence address for correspondence.
- 4. Driver Phone Number: The contact phone number of the driver.
- 5. City/State/Zip Code: The driver's city, state, and postal code.
- 6. Member ID: Unique identification number assigned to the member.
- 7. Member Name: Name of the member receiving transportation services.
- 8. Trip Date: Date of the trip/service provided.
- 9. Trip Number: A unique identifier for each trip.
- 10. Medical Provider Name & Phone Number: The name and contact number of the medical provider.
- 11. Provider Signature: Signature of the medical provider confirming the trip details.
- 12. Total Miles: The total distance traveled for each trip.
What happens if I fail to submit this form?
Failure to submit the form may result in not receiving reimbursement for the transportation services provided. It is crucial to adhere to the submission deadline to avoid any issues.
- Delayed Reimbursement: Submitting late may cause delays in processing your reimbursement.
- Denial of Reimbursement: Incomplete or late submissions could lead to denial of reimbursement requests.
- Inefficiency in Record Keeping: Failure to submit on time results in inaccurate records, affecting overall financial management.
How do I know when to use this form?
- 1. Transportation Reimbursement: When claiming mileage reimbursement for trips.
- 2. Trip Verification: To verify and document the details of transportation service trips.
- 3. Provider Validation: To get the signature of the medical provider confirming the trip.
- 4. Administrative Record: To ensure accurate record-keeping of trips and miles logged.
- 5. Caregiver Assistance: For caregivers or representatives helping members document trips for reimbursement.
Frequently Asked Questions
How do I fill out the Secure Transportation Reimbursement Log?
Begin by providing the driver's information, then enter the member's ID and trip details. Ensure each trip entry is signed by the medical provider.
Can I edit this reimbursement log on PrintFriendly?
Yes, you can easily edit the log using PrintFriendly's PDF editor to add or modify text fields.
How do I sign the reimbursement log on PrintFriendly?
Use PrintFriendly's digital signature tool by clicking the 'Sign' button and placing your signature in the required field.
Can I share the edited reimbursement log on PrintFriendly?
Yes, you can share the edited log via a shareable link or email using PrintFriendly's sharing feature.
Who needs to use this reimbursement log?
Secure Transportation drivers, members, medical providers, administrative staff, and caregivers need this log for reimbursement purposes.
What information do I need to provide in the reimbursement log?
You need to provide driver and member details, trip dates and numbers, medical provider's information, and obtain provider's signatures.
Is there a deadline for submitting the reimbursement log?
Yes, the form must be submitted to Secure Transportation within 90 days of the service date.
Can I edit the reimbursement log on my mobile device?
Yes, PrintFriendly's PDF editor is mobile-friendly and allows you to edit the log on your mobile device.
How do I upload my reimbursement log to PrintFriendly?
Click on the 'Upload' button on PrintFriendly's website or app, and select your reimbursement log PDF file to begin editing.
What happens if my reimbursement log is incomplete?
Incomplete logs may result in delayed or denied reimbursements. Ensure all required information and signatures are provided.
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