AZ AHCCCS Exh 11-1 Daily Trip free printable template
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Ex 111 DAILY TRIP REPORT Driver Name: Date: Vehicle # type Name of Recipient Pickup time Pick up odometer Drop off time Drop off odometer Recipient Signature Trip miles Pick up location & address
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How to fill out AZ AHCCCS Exh 11-1 Daily Trip Report
01
Begin by entering the date at the top of the form.
02
Fill in the driver's name and ID number.
03
Specify the type of service provided (e.g., ambulett, wheelchair, etc.).
04
Record the start and end times of the trip.
05
Input the starting and ending odometer readings to capture mileage.
06
Note the origin and destination addresses for the trip.
07
List the passengers being transported and their respective identification numbers.
08
Indicate any special instructions or notes relevant to the trip.
09
Ensure all fields are complete and accurate before submission.
10
Submit the completed report to the appropriate AHCCCS authority.
Who needs AZ AHCCCS Exh 11-1 Daily Trip Report?
01
Transportation providers offering services under the Arizona Health Care Cost Containment System (AHCCCS).
02
Drivers who need to document their daily trips for reimbursement or reporting purposes.
03
Agencies responsible for compliance with AHCCCS transportation services guidelines.
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What is AZ AHCCCS Exh 11-1 Daily Trip Report?
The AZ AHCCCS Exh 11-1 Daily Trip Report is a document used by transportation providers in Arizona's Medicaid program to record and report on the non-emergency medical transportation (NEMT) trips made on a daily basis.
Who is required to file AZ AHCCCS Exh 11-1 Daily Trip Report?
Transportation providers that offer services under the Arizona Health Care Cost Containment System (AHCCCS) are required to file the AZ AHCCCS Exh 11-1 Daily Trip Report.
How to fill out AZ AHCCCS Exh 11-1 Daily Trip Report?
To fill out the AZ AHCCCS Exh 11-1 Daily Trip Report, transportation providers must provide details such as the date, the driver's name, trip locations, patient information, mileage, and any additional notes as required by AHCCCS guidelines.
What is the purpose of AZ AHCCCS Exh 11-1 Daily Trip Report?
The purpose of the AZ AHCCCS Exh 11-1 Daily Trip Report is to ensure accurate tracking and documentation of transportation services provided to AHCCCS members, which is essential for billing and compliance with state regulations.
What information must be reported on AZ AHCCCS Exh 11-1 Daily Trip Report?
The AZ AHCCCS Exh 11-1 Daily Trip Report requires reporting of information including trip dates, patient names, pickup and drop-off addresses, the type of service provided, mileage, and any special instructions or notes regarding the trips.
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