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Mileage Reimbursement Verification Form Single

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hbriding
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108 views1 page

Mileage Reimbursement Verification Form Single

Uploaded by

hbriding
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Mileage Reimbursement Verification Form (Single Trip)

Please complete this form and return it to IntelliRide for reimbursement of your mileage within 10
business days of your medical appointment. To qualify for reimbursement, your trip must be scheduled
with IntelliRide, assigned to mileage reimbursement, and your medical provider must verify your
attendance at your pre-scheduled healthcare appointment.

Patient First Name Last Name DOB Health First Colorado ID #


Information

Trip Date of Trip Appointment Time Trip Confirmation # (from IntelliRide)


Information

Facility Name

Facility Address, City, State & Zip

Medical Medical Provider's Name & Title


Facility
Information
Contact Name & Title

Contact Phone Contact Email

With my signature, I hereby acknowledge that the above named Health First Colorado patient was seen in our
office on the date and at the time identified above. I understand that if I have given false information or
intentionally failed to disclose information, I may be subject to prosecution, criminal, civil, or both. I certify under
penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the
Medical information provided is accurate to the best of my knowledge.
Provider Printed Name of Facility Staff Title
Attestation

Signature of Facility Staff Date

Driver's Name Driver's Phone

Driver
Information Driver's Mailing Address City State Zip

IntelliRide Use Only


Trip Confirmation #(s): Number of Trip Legs Total Miles

Total Miles Approval Status / Agent Initials Date

Fax: (402) 934‐8622 Mail:


[email protected] 2222 Cuming Street Omaha, NE 68102

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