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How do I fill this out?
To fill out this form, start by calling the ModivCare Reservation Line to schedule your trip. Be sure to record the job number and date of your trip on the form. Finally, have your healthcare provider sign the form to verify your appointment.
How to fill out the ModivCare Mileage Reimbursement Guidelines?
1
Call the Reservation Line and obtain a job number.
2
Fill out the form completely except for the Physician/Clinician space.
3
Secure your doctor's signature on the form.
4
Mail the completed form to the ModivCare Claims Department.
5
Your payment will be processed within the specified timeframe.
Who needs the ModivCare Mileage Reimbursement Guidelines?
1
Patients who frequently visit medical appointments and need to claim travel expenses.
2
Family members who drive patients to appointments and need reimbursement for mileage.
3
Healthcare providers who assist patients in submitting their reimbursement forms.
4
Caregivers managing budget for medical-related travel for those they care for.
5
Individuals utilizing ModivCare services for insurance-related travel reimbursements.
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1
Open the ModivCare reimbursement PDF in PrintFriendly.
2
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What are the instructions for submitting this form?
To submit this form, mail your completed document to the ModivCare Claims Department at 798 Park Avenue NW, Norton, VA 24273. You can also fax it to 1-800-486-7642 for quicker processing. Ensure all required signatures and information are filled out correctly to avoid delays in reimbursement.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, be sure to check ModivCare's website for any critical submission deadlines and payment schedules. Compliance with the specific dates ensures timely processing of reimbursements for your trips to medical appointments.
What is the purpose of this form?
The ModivCare mileage reimbursement form is designed to help members claim travel expenses incurred while attending medical appointments. Proper submission ensures that individuals can receive compensation for rides provided by family members or friends. By filling out this form accurately, members can secure the funds necessary for their travel.
Tell me about this form and its components and fields line-by-line.
- 1. Trip Number: A unique number assigned at the time of scheduling your trip.
- 2. Date of Travel: The date you traveled to your medical appointment.
- 3. Driver's Name: The name of the person who drove you for the trip.
- 4. Healthcare Provider Signature: A signature from your doctor confirming your visit.
- 5. Mileage: The number of miles traveled to the appointment location.
What happens if I fail to submit this form?
Failing to submit this form with the required details can result in rejected claims for reimbursement. If your submission lacks essential information such as the job number, your request will not be processed. It is crucial to adhere strictly to the guidelines provided.
- Missing Job Number: Submission without a job number can lead to denial of your reimbursement.
- Incomplete Form: Not filling out all necessary fields may cause delays in processing.
- Lack of Signature: Forms sent without a healthcare provider's signature are invalid.
How do I know when to use this form?
- 1. Scheduled Medical Appointments: Use this form whenever you attend a medical appointment.
- 2. Claiming Mileage for Family Drivers: If a family member drives you, they can be reimbursed for their mileage.
- 3. Documentation of Travel: This form serves as proof when documenting your travel for reimbursement.
Frequently Asked Questions
How do I obtain a job number?
You can get a job number by calling the ModivCare Reservation Line.
Is there a limit to how many trips I can claim?
Yes, up to eight one-way trips can be claimed on one form.
What do I need to submit this form?
You need to complete the form and have it signed by your healthcare provider.
How will I receive my payment?
Your check will be mailed once your claim is processed.
Who can drive me and be reimbursed?
Only one driver can be named per form for reimbursement.
What if my mileage is incorrect?
Ensure you verify your mileage during the reservation call.
Can I call if I have questions about my reimbursement?
Yes, call the ModivCare customer service for any inquiries.
How long does it take to process claims?
Allow up to 10 business days for processing before following up.
What do I do if I forget to include my job number?
If you forget, your reimbursement might be denied.
Where do I send my completed form?
Mail it to the ModivCare Claims Department as specified on the form.
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