Get the free Mileage Reimbursement Form - Louisiana Healthcare Connections

Mileage Reimbursement Trip Log www.LogistiCare.com Must be mailed to:MEMBER NAME:MEMBER ID#:DRIVER NAME:RELATIONSHIP TO MEMBER:DRIVER MAILING ADDRESS:DRIVER PHONE #:Logistical Claims Department 2552

How to fill out mileage reimbursement form

How to fill out mileage reimbursement form

1. Start by entering your personal information, such as your name, address, and contact details, in the respective fields of the reimbursement form.
2. Specify the purpose of the travel and the relevant date(s) for which you are seeking reimbursement.
3. Record the starting and ending mileage of your trip, as well as the total distance traveled.
4. Indicate the mode of transportation used for the travel, whether it is your personal vehicle or another means.
5. If using a personal vehicle, provide details such as the make, model, and license plate number.
6. Include any additional expenses incurred during the trip, such as toll fees or parking charges.
7. Calculate the total reimbursement amount by multiplying the total distance traveled with the appropriate mileage rate.
8. Attach supporting documentation, such as fuel receipts or parking receipts, to validate your expenses.
9. Review the completed form for accuracy and make any necessary revisions.
10. Sign and date the reimbursement form before submitting it to the appropriate department or supervisor.

Who needs mileage reimbursement form?

1. Mileage reimbursement forms are typically needed by individuals who use their personal vehicles for business purposes and are entitled to receive reimbursement for the mileage traveled.
2. This may include employees who frequently travel for work, sales representatives, delivery drivers, or any other individuals who are required to use their own vehicles for work-related tasks.

People Also Ask about

Can I get gas with my Louisiana Healthcare Connections card?

Use your My Health Pays® rewards to help pay for: Utilities. Transportation. Telecommunications.

How to start transportation service in Louisiana?

In order to operate a transportation business in Louisiana, you must obtain a business license from the Louisiana Department of Transportation and Development. The license application must be accompanied by a fee, and you must also submit proof of insurance.

How do I schedule a ride with Louisiana Healthcare Connections?

To schedule by phone, call 1-855-369-3723, Monday – Friday from 7 a.m. to 7 p.m., excluding holidays. Or schedule your ride online. Transportation requests for medical appointments not made at least 48 hours in advance may be denied. This 48-hour notice does not apply to rides to Urgent Care.

Is Louisiana Healthcare Connections the same as Louisiana Medicaid?

Louisiana Healthcare Connections provides the same benefits as Medicaid, plus more. In this section, you can learn about the health benefits, pharmacy services and value added services Louisiana Healthcare Connections offers.

How do I start a non emergency medical transportation in Louisiana?

Complete a MT-10 Form (enclosed) and submit it to the Louisiana Public Service Commission. Register the vehicle with the Louisiana Department of Public Safety, Office of Motor Vehicles. You must register the vehicle in your business name and you must purchase a “For Hire” license plate.

How do I contact Louisiana Healthcare Connections?

Do you need more information or have a question? Please fill out the below form or contact us at 1-866-595-8133 (TTY: 711), Monday through Friday, 7a.

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What is mileage reimbursement form?

Mileage reimbursement form is a document used to request reimbursement for the miles driven for work purposes.

Who is required to file mileage reimbursement form?

Employees who use their personal vehicles for work purposes and are eligible for mileage reimbursement are required to file the form.

How to fill out mileage reimbursement form?

To fill out the mileage reimbursement form, employees need to provide details such as date of travel, starting location, destination, total miles driven, and purpose of the trip.

What is the purpose of mileage reimbursement form?

The purpose of mileage reimbursement form is to ensure that employees are properly compensated for the miles they drive for work.

What information must be reported on mileage reimbursement form?

Employees must report details such as date of travel, starting location, destination, total miles driven, and purpose of the trip on the mileage reimbursement form.