Mileage Reimbursement Trip Log and Invoice Instructions - Rev. 05-2021

Sep 19, 2026

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Mileage reimbursement trip log instructions guide beneficiaries on requesting and completing mileage reimbursement forms. The document explains scheduling trips and recording the trip number and trip date, filling out the form except for the “Physician/Clinician Signature” field, and obtaining provider confirmation at the medical visit. It sets limits such as up to seven trips per form and only one driver per form, then details submission methods, mailing/email/fax addresses, timing requirements, and expected payment processing windows.

LanguageEnglish

CategoryInvoices

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Mileage reimbursement steps

Required trip number and form completion

Physician/clinician signature and provider confirmation

Trip limits and driver restrictions

Submission methods and deadlines

Driver information

Record of trips

Member information

Signatures and payment processing notes

Mileage Reimbursement Trip Log and Invoice Instructions Dear beneficiary, We have enclosed a blank reimbursement form with this letter along with instructions and a sample log for guidance. Feel free to make copies of the blank form for any future trips. You can also contact the ModivCare Reservation Line as well as visit [ModivCare.com](ModivCare.com) to obtain additional blank copies of the form. Below outlines how to be reimbursed for mileage: 1. When you call to schedule your trip, you will receive a trip number. This trip number is required on the reimbursement form. Write down the trip number and date of your trip on the reimbursement form as soon as you get it from the ModivCare reservation specialist. Forgetting to add this is a common mistake and will cause your reimbursement to be denied. Be sure to add it to your form before you forget! 2. You must fill out the entire form except for the space for "Physician/Clinician Signature" . 3. Take the form with you to your medical appointment and have your doctor or counselor sign it. Your doctor or counselor should sign in the "Physician/Clinician Signature" space on the form. Please note that your doctor/counselor must sign the form as proof that you were at your appointment. 4. You can put up to seven trips on one form. 5. Please note that there can only be one driver on a form. You must complete and send a separate form for each of the people driving you to your medical appointments. 6. Once your form is complete, please send your form via mail, email or fax. Mail: 798 Park Avenue NW, Norton, VA 24273 [Email: Virginia.billingoperations@modivcare.com](Email: Virginia.billingoperations@modivcare.com) [Fax: 866-528-0462](Fax: 866-528-0462) 7. The request for reimbursement is required on or before the day of the medical appointment, and the voucher must be received within 30 days or it may be denied. If you are listing more than one appointment, you must submit the completed form within 30 days from the earliest appointment shown. 8. Payment will be mailed within thirty (30) business days of the ModivCare Claims Department receiving your completed reimbursement form. If you have any questions, please call ModivCare Claims Department at 1-800-930-9060. Thank you, Modivcare RESPECT • TRUST • RELIABLE • COMPASSION • SAFETY • TRANSPARENCY Rev. 05-2021 DRIVER INFORMATION | Driver’s Name | | | Driver’s Address (Street) | | | | --- | --- | --- | --- | --- | --- | | Driver’s License \# | Driver’s License State | | City | State | Zip Code | | SIGNATURE OF DRIVER
I 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. | | | | | | | X | | | Date | | | | Signature | | | | | | RECORD OF TRIPS Each 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 | | Trip Date | Trip Number | Total Miles | Provider Name | Provider Phone Number | Physician / Clinician Signature | | --- | --- | --- | --- | --- | --- | --- | | 1 | | | | | | | | 2 | | | | | | | | 3 | | | | | | | | 4 | | | | | | | | 5 | | | | | | | *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. MEMBER INFORMATION | Relationship to Member | Member Name | Member ID | | --- | --- | --- | SIGNATURE OF MEMBER I hereby agree the above information is true and correct. I have also received, read and agreed to the gas reimbursement guidelines. X Member Sign

FAQs

Where do beneficiaries get the trip number, and when must it be written on the form?

The trip number is provided when scheduling the trip. It must be written on the reimbursement form along with the trip date as soon as it is received.

What parts of the mileage form must the beneficiary complete, and what is left for the physician or clinician?

Beneficiaries must fill out the entire form except the “Physician/Clinician Signature” space. The doctor or counselor must sign in that space to verify the appointment attendance.

How many trips can be included on one form, and can multiple drivers be listed together?

Up to seven trips can be listed on one form. Only one driver can be on a form, so a separate form is required for each person driving.

Sep 19, 2026

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