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Includes a standing order option and a weekly travel selector, then records each trip’s date, trip number, total miles, provider identity, contact number, and physician/clinician signature. Also collects member information, relationship to member, member ID, and member signature acknowledging gas reimbursement guidelines. 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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.  \nX  \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)  \nFor questions about your claim, call 1-800-930-9060.","cbCaiutWbGSgeHxw","https://ap.wps.com/l/cbCaiutWbGSgeHxw","pdf",171285,"English","# Driver Information\n## Record of Trips\n## Member Information\n## Submission Instructions","[{\"question\":\"What information must be provided in the driver section?\",\"answer\":\"The form collects the driver’s name, address, driver’s license number and state, city, state, and zip code, along with a driver signature confirming required eligibility statements and insurance/license status.\"},{\"question\":\"How are trips recorded on the form?\",\"answer\":\"Each service date is listed with fields for trip date, trip number, total miles, provider name and provider phone number, plus a physician/clinician signature for the trip.\"},{\"question\":\"What does the member signature confirm?\",\"answer\":\"The member signature confirms that the information is true and correct and that the gas reimbursement guidelines have been received, read, and agreed to.\"}]","Mileage Reimbursement Trip Log and Invoice | PDF",1789846237]