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Medicaid Trip Reimbursement

Submit a trip reimbursement claim to Medicaid / health plan

Your Contact Information

Your Name *

Your Email *

Your Phone

Patient Information

Patient Name *

Date of Birth

Medicaid ID *

Authorization Number

Health Plan

Health Plan Name

Health Plan ID

Trip Details

Trip Date *

Pickup Time

Dropoff Time

Mobility Type

Trip Purpose

Return Trip

Pickup Address *

Destination Address *

Mileage & Charges

Mileage

Rate per Mile ($)

Base Rate ($)

Tolls ($)

Wait Time (min)

Wait Time Rate ($/hr)

Calculated Total: $0.00

Driver & Vehicle

Driver Name

Driver ID

Vehicle ID

Vehicle Type

Attendant Name