CHILD FOSTER CARE MILEAGE FORM
(Initial 150 Miles)
Month/Year:
Foster Home:
Child Name:
Social Worker:
Please refer to the next page for mileage reimbursement instructions.
DATE
TRIP PURPOSE AND DESTINATION
MILES
Total Miles
Foster Parent Signature:
Date:
Rev. 02/03/2020
0
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Mileage Reimbursement:
Do not enter medical miles (i.e. doctor appointments, therapist, occupational
or physical therapy etc.) on this form. All medical mileage reimbursement is
required to go through MTM non-emergency medical transportation
Services, phone #1-844-399-9466. Please contact your case manager or
licensor if you have any questions regarding medical mileage.
The foster care MAPCY rate includes 150 miles per child (visitation,
education, cultural events, etc.). You will need to get approval from the case
manager on what can be counted as mileage. Reminder medical mileage is
not included and is reimbursed separately.
If you go over 150 miles for the month per child, you can get reimbursed
with permission from the case manager.
You cannot claim mileage for multiple children on a trip. If the children
both have an appointment divide the total miles and then assign to each
child.
o Example- 2 children have visits and it is 10 miles to the visit center.
If foster parent drives 10 miles to the visit and then 10 miles back
home, comes back to pick up the children 10 miles and then goes back
home 10 miles. The total trip is 40 miles for that trip. Divide 40 miles
by 2 children, assign each child 20 miles. Same scenario, but the visit
was only for one of the children and the other child was in the car to
tag along. The one child who has the visit would have 40 miles and
the other child would have 0.
Keep a log of your record and email/mail a copy to your social worker.
***PLEASE TURN IN YOUR TRAVEL LOG WITHIN THE
1
st
WEEK OF THE FOLLOWING MONTH.***
Additional mileage logs can be found under forms in the foster care
section of the
St. Louis County Public Health and Human Service
website:
https://www.stlouiscountymn.gov/departments-a-z/public-
health-human-services/children-family-services