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How to fill out logisticare gas reimbursement form

How to fill out Logisticare gas reimbursement form:

1. Start by entering your personal information, including your name, address, phone number, and email address.
2. Provide your date of birth and social security number for identification purposes.
3. Indicate whether you are the patient or the caregiver filling out the form.
4. Enter the patient's name, date of birth, and Medicaid number if applicable.
5. Specify the date of service for which you are seeking gas reimbursement.
6. Enter the starting address of the trip and the destination address.
7. Indicate the total number of miles traveled for this trip.
8. Calculate the total cost of gas used for the trip. Make sure to keep all receipts as proof of purchase.
9. Provide any additional information or documentation required by Logisticare or your Medicaid program.
10. Lastly, sign and date the form to certify that the information provided is accurate and complete.

Who needs Logisticare gas reimbursement form:

1. Patients who rely on Medicaid transportation services for medical appointments may need to fill out the Logisticare gas reimbursement form.
2. Caregivers who accompany patients to their medical appointments and are responsible for their transportation may also need to complete this form.
3. It is important to check with your Medicaid program or Logisticare to determine if the gas reimbursement form is required and if you are eligible for reimbursement.

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What is logisticare gas reimbursement form?

LogistiCare Gas Reimbursement Form is a document used to request reimbursement for gas expenses incurred while using LogistiCare services.

Who is required to file logisticare gas reimbursement form?

Anyone who has incurred gas expenses while using LogistiCare services is required to file the Gas Reimbursement Form.

How to fill out logisticare gas reimbursement form?

To fill out the LogistiCare Gas Reimbursement Form, you must provide your name, address, date of service, vehicle mileage, and total gas expenses.

What is the purpose of logisticare gas reimbursement form?

The purpose of the LogistiCare Gas Reimbursement Form is to request reimbursement for gas expenses incurred while using LogistiCare services.

What information must be reported on logisticare gas reimbursement form?

Information such as your name, address, date of service, vehicle mileage, and total gas expenses must be reported on the LogistiCare Gas Reimbursement Form.