Mileage Reimbursement Forms
Interested in you, a family member or a friend driving you to your clinical appointment? Depending on your health plan, you could get paid back for going to your medical appointment. To make sure you are paid, your doctor must sign a form showing you went to your appointment.
Mileage Reimbursement standard form for all states (excluding Florida and Texas):
Here's how it works
Write the date of the scheduled trip on the form
When you schedule your trip, as soon as you get the trip number, write it on the form! Write the date of the trip on the form too! If you forget to write the trip number and date on the form, it will keep you from getting paid. So, be sure to add it to your form before you forget!
Fill out the entire form
You must fill out the entire form except for the space for “Physician/Clinician Signature”.
Take the form with you to your appointment
Take the form with you to your clinical appointment and have your doctor or counselor sign it. Your doctor or counselor should sign in the “Physician/Clinician Signature” space on the form.
You can use the form for more than one trip.
Please note that there can only be one driver on a form
A new form has to be filled out for each person driving you to see your doctor.
Once your form is complete, follow the instructions on the form to submit.
When we receive your form, we will mail your payment.
Contact us if you have any questions.