Mail to:
LogistiCare Claims Department
798 Park Avenue NW
Norton, VA 24273
TRIP LOG
Driver name: ____________________________________________ Member name:______________________ ___________
Driver address: __________________________________________ Member ID _____________________________________________
City: ___________________State: _______ Zip Code: ___________ Driver relationship to member:_______________________
Driver phone: ( )
Total mileage to be paid: Total amount for this form: Batch #: Batch date:
This information is private. It must not be given to anyone. It is not part of the freedom of information act or open records law.
DATE OF TRIP TRIP NUMBER DOCTOR NAME AND PHONE NUMBER PHYSICIAN/CLINICIAN
SIGNATURE
NUMBER OF MILES DRIVEN
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Your doctor must sign this form for you to get paid. Your doctor will confirm your visit before you get paid.
_________________________________________ No writing below this line________________________________________________
Mail to:
LogistiCare Claims Department
798 Park Avenue NW
Norton, VA 24273
TRIP LOG
Driver name: ____________________________________________ Member name:______________________ ___________
Driver address: __________________________________________ Member ID _____________________________________________
City: ___________________State: _______ Zip Code: ___________ Driver relationship to member:_______________________
Driver phone: ( )
Total mileage to be paid: Total amount for this form: Batch #: Batch date:
This information is private. It must not be given to anyone. It is not part of the freedom of information act or open records law.
This information is available for free in other languages. Please contact our customer
service number at 1-866-796-0530, TDD 1-800-955-8770 Monday through Friday, 8 a.m.
to 8 p.m. Sunshine Health complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex.
Esta información está disponible en otros idiomas de manera gratuita. Comuníquese con
nuestro número de servicio al cliente al 1-866-796-0530, TDD 1-800-955-8770 de lunes a
viernes, de 8 a.m. a 8 p.m. Sunshine Health cumple con las leyes de derechos civiles
federales aplicables y no discrimina basándose en la raza, color, origen nacional, edad,
discapacidad, o sexo.
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