Medical Transportation Client Reimbursement Form - Olmsted County Community Services
Download a blank fillable Medical Transportation Client Reimbursement Form - Olmsted County Community Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Transportation Client Reimbursement Form - Olmsted County Community Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2OLMSTED COUNTY COMMUNITY SERVICES
REQUIRED DOCUMENTATION:
FAMILY SUPPORT AND ASSISTANCE DIVISION
(We cannot reimburse you if this information is not available):
2117 CAMPUS DRIVE SE, SUITE 100
Receipts - attach all lodging , meals and non mileage transportation receipts
ROCHESTER, MN 55904-4825
Olmsted County does not reimburse for alcoholic beverages.
Mileage and parking - destination and purpose - PARKING MUST SEND IN ORIGINAL RECEIPTS
MEDICAL TRANSPORTATION CLIENT EXPENSE REIMBURSEMENT FORM
Mileage rate for vested interest vehicle (R)-.20 per mile (self, neighbor, friend, or relative)
RETURN TO ELIGIBILITY WORKER
Mileage rate for non-vested interest vehicle (NR)- IRS rate (volunteer drivers or organizations)
MA Client's Name __________________________________________
Prior Authorized Lodging- Not to exceed $50/day unless prior authorized.
MA Number______________Sex________Date of Birth_____________
Pre-approved Meals- Maximum including tax and gratuity: MUST SEND IN ORIGINAL RECEIPTS
Expense for the month of __________________________,20________
(B) Breakfast- $5.50, (L) Lunch- $6.50 and (D) Dinner- $8.00
Make payment to : (Name of driver)
Name
______________________________________________________
**Please do not submit for reimbursement until you have a minimum of $20 in expenses**
Street/P.O. Box
______________________________________________________
**County will hold onto submitted reimbursement until minimum is met**
City, State, Zip
_____________________________________________________
Phone
(____)___________________
(Co Use Only)
APPROVED
Vehicle
# OF
Mileage
MEALS
LODGING PARKING OTHER
DATE
REQUIRED DOCUMENTATION
(R or NR)
MILES
Amount
AMOUNT
FROM
B
TO
L
PURPOSE OF TRIP:
D
DESTINATION:
NAME OF PERSON(S) SEEN:
FROM
B
TO
L
PURPOSE OF TRIP:
D
DESTINATION:
NAME OF PERSON(S) SEEN:
FROM
B
TO
L
PURPOSE OF TRIP:
D
DESTINATION:
NAME OF PERSON(S) SEEN:
ACCOUNTING USE ONLY
OFFICE USE ONLY
TOTAL REQUEST FOR REIMBURSEMENT
GAX #
INIT
DATE
I hereby certify that I was Medical Assistance eligible during the period these expenses were incurred
ORDERED-GOODS RECD
and that the expenses listed are accurate and eligible under the Medical Assistance program.
VERIFIED MATH FOR ACCURACY
APPROVED FOR PAYMENT
DATE
Claimant's Name- Printed
GAX TOTAL
VEND #
FUND
DEPT
UNIT
OBJT
RPT
Claimant's Signature
**Reimbursements should be submitted at least quarterly or by the 10th of the month**
**We are unable to reimburse requests older than 11 months**
T:\Suzann\Dept\Medical Transportation\Templates for Med Tran\Client Reimbursement Form 9-18-12.xlsx
9/19/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical