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Physician Attestation/Mileage Reimbursement Form Invoice #:S0215Date:___/___/___CM:(2) Medicaid Recipient: Medicaid (CIN) #:(3) Claimant Name (Only if other than recipient): Name:Name:Address:Address:City,
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How to fill out nys-doh-mileage-reimbursement-formpdf

01
Download the NYS DOH Mileage Reimbursement Form PDF from the official website.
02
Fill in your name, address, and contact information at the top of the form.
03
Enter the date of travel in the designated field.
04
Indicate the starting point and destination of your trip.
05
Record the total number of miles traveled in the mileage section.
06
Provide a brief description of the purpose of the travel.
07
Attach any necessary supporting documentation, such as maps or travel itineraries.
08
Sign and date the form at the bottom.

Who needs nys-doh-mileage-reimbursement-formpdf?

01
Individuals who are seeking reimbursement for mileage incurred while performing state-related duties or travel.
02
Employees of organizations working on behalf of the New York State Department of Health.
03
Volunteers or contractors who need to claim mileage during official state business.
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The NYS DOH Mileage Reimbursement Form is a document that allows individuals to request reimbursement for mileage expenses incurred while traveling for Department of Health-related activities in New York State.
Individuals who are employees, contractors, or volunteers working on behalf of the New York State Department of Health and who incur travel expenses related to their duties are required to file this form.
To fill out the form, follow the instructions provided, which typically include entering your personal information, the dates of travel, destinations, total miles driven, and any supporting documentation for your expenses.
The purpose of the form is to ensure that eligible individuals can receive reimbursement for business-related mileage expenses incurred while performing their duties for the New York State Department of Health.
The information that must be reported includes the claimant's name, address, the date of travel, starting and ending addresses, total mileage, purpose of the trip, and any required signatures.
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