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States an eligibility restriction for California Medi-Cal beneficiaries and lists submission details, processing timelines, and office-use financial fields for total mileage, invoice amount, batch number, and batch date.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/invoices/","Invoices",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/mileage-reimbursement-trip-log-and-invoice-final/307242/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/mileage-reimbursement-trip-log-and-invoice-final/307242.png","ImageObject",442,249,{"name":42,"@type":43},"Stanford","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-17","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must sign the trip log and when is it reviewed?","Question",{"text":63,"@type":64},"Each date of service requires a physician or clinician signature. The log is reviewed with the physician's office before payments are made.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What eligibility rule applies to California Medi-Cal beneficiaries?",{"text":68,"@type":64},"California members are not eligible for mileage reimbursement if they drive themselves to their appointment, per All Plan Letter 17-010.",{"name":70,"@type":61,"acceptedAnswer":71},"Where and how should completed forms be submitted?",{"text":72,"@type":64},"Completed forms can be sent by mail, fax, or email to the addresses and contacts listed on the form, and payment processing may take 4–6 weeks.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},307242,1790296088,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":96,"slug":97},14,70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":95,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},2336477552062,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE  \nDRIVER INFORMATION  \n\n| Driver’s Name |  | Driver’s Address (Street) |  |  |\n| --- | --- | --- | --- | --- |\n| Driver’s License \\# | Driver’s License State | City | State | Zip Code |\n\nSIGNATURE OF DRIVER  \nI confirm by sending this log to agree I have a current, valid, and open driver's license; that the vehicle used to perform services has passed allstate tests and is currently state registered and insured according to the laws and regulations of the state to which is registered.  \n X     \nDriver Signature Date  \nRECORD OF TRIPS  \nEach date of service must have a physician or clinician signature and will be reviewed with the physician's office before payments will be made. Is Trip a Standing Order?  Yes  No Standing Order Days of Traveled Weekly  S  M  T  W  Th  F  S  \n\n|  | Trip Date | Trip Number | Total Miles | Provider Name | Provider Phone Number | Physician / Clinician Signature |\n| --- | --- | --- | --- | --- | --- | --- |\n| 1 |  |  |  |  |  |  |\n| 2 |  |  |  |  |  |  |\n| 3 |  |  |  |  |  |  |\n| 4 |  |  |  |  |  |  |\n| 5 |  |  |  |  |  |  |\n\n*For California members: Per All Plan Letter 17-010 from the California Department of Health Care Services, Medi-Cal beneficiaries who drive themselves to their appointment are NOT eligible for mileage reimbursement.  \nMEMBER INFORMATION  \n\n| Relationship to Member | Member Name | Member ID |\n| --- | --- | --- |\n\nSIGNATURE OF MEMBER  \nI hereby agree the above information is true and correct. I have also received, read and agreed to the gas reimbursement guidelines.  \n X     \nMember Signature Member Name (Print)  \nCompleted forms can be sent to:  \nMail: 798 Park Avenue NW, Norton, VA 24273 Fax: 866-528-0462 Email: [support.claims@modivcare.com](support.claims@modivcare.com)[ ](support.claims@modivcare.com)Please allow 4-6 weeks for payment to be processed. For questions about your claim, call 1-800-930-9060.  \n\n| For Office Use Only |  |  |  |\n| --- | --- | --- | --- |\n| Total mileage to be paid | Total invoice amount | Batch number | Batch date |","cbCaib2xa4FfiF6Z","https://ap.wps.com/l/cbCaib2xa4FfiF6Z","pdf",173176,"English","# Driver Information\n# Record of Trips\n# Member Information\n# Signatures\n# Submission and Payment Processing\n# For Office Use Only","[{\"question\":\"Who must sign the trip log and when is it reviewed?\",\"answer\":\"Each date of service requires a physician or clinician signature. The log is reviewed with the physician's office before payments are made.\"},{\"question\":\"What eligibility rule applies to California Medi-Cal beneficiaries?\",\"answer\":\"California members are not eligible for mileage reimbursement if they drive themselves to their appointment, per All Plan Letter 17-010.\"},{\"question\":\"Where and how should completed forms be submitted?\",\"answer\":\"Completed forms can be sent by mail, fax, or email to the addresses and contacts listed on the form, and payment processing may take 4–6 weeks.\"}]","Mileage Reimbursement Trip Log and Invoice - Final | PDF",1789846194]