Gas Reimbursement Form - Free Download
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Nevada Gas Mileage Reimbursement
Form
Check should be made payable to: Medicaid Recipient Information:
Name: Name:
Social Security: Medicaid ID No.:
Mailing Address: Name of Attendant:
City:
State: Zip:
Date Job Number Member Name Total Miles Doctor's Name
LogistiCare
Doctor's Signature or Stamp/Acceptable documents
are Doctor Receipt or Pharmacy slip
Saturday
2552 W. Erie Drive, Ste. #101
Logisticare-Attn:Nevada Claims
Day
Sunday
Monday
Tuesday
**Please be advised that gas reimbursement will only be paid after the 25th mile one way or at the 50th mile in one week. This reimbursement will be paid at $0.24 cents per mile. For
an approved GR/Volunteer driver the reimbursement will be paid at $0.48 from mile one.
Wednesday
Call LogistiCare Billing Department at 1-877-564-5665 for claim inquiries only. All other inquiries call NV office at 1-888-737-0829
MAIL TO:
Tempe, AZ 85282
Thursday
Friday
All trips that are scheduled within a week should be
included on this form.
IMPORTANT: Form must be filled out completely in order to receive reimbursement.
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