logisticare transportation forms 2018

Get the SC Gas Mileage Reimbursement Trip Log 2011-2020

SOUTH CAROLINA GAS MILEAGE REIMBURSEMENT TRIP LOG Must be sent to DRIVER NAME DRIVER MAILING ADDRESS CITY/STATE/ZIP MEMBER NAME If different from Driver Trip Date Trip/Job LogistiCare Claims Department 503 Oak Place Suite 550 College Park GA 30349 RELATIONSHIP TO MEMBER DRIVER PHONE MEMBER ID Medical Provider Name Phone Physician/Clinician Signature Total Miles Name Phone Each date of service must have a physician or clinician signature in order for reimbursement to be approved. NOTE Each...
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