Transportation Reimbursement Submission Request

Trips must be to or from plan-approved locations, such as network providers, medical facilities, pharmacies, or hearing and vision appointments. If a member is privately transported to dialysis service appointments (not using our transportation benefit), the private driver may be reimbursed by our plan. See your evidence of coverage, Chapter 4 benefits chart for more information.

Please fill out the form below and include all information prior to submitting. Claims payments for transportation reimbursement can take up to 14 days.

"*" indicates required fields

Member Information

Member Name*

First Last

Member ID*

Date of Birth*

Member Address*

Street Address City State ZIP / Postal Code

Member Email*

Member Phone Number*

Driver Information

Name*

First Last

Phone Number*

Relationship to Member*

Reimbursement Details

Please indicate person for reimbursement:*

Member

Driver

Address for reimbursement to be sent to:

Same address as listed above

New Address

Address for reimbursement to be sent to:*

Street Address City State ZIP Code

Enter 1st Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 2nd trip for reimbursement?

Yes

Enter 2nd Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 3rd trip for reimbursement?

Yes

Enter 3rd Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 4th trip for reimbursement?

Yes

Enter 4th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 5th trip for reimbursement?

Yes

Enter 5th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 6th trip for reimbursement?

Yes

Enter 6th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 7th trip for reimbursement?

Yes

Enter 7th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 8th trip for reimbursement?

Yes

Enter 8th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 9th trip for reimbursement?

Yes

Enter 9th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 10th trip for reimbursement?

Yes

Enter 10th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 11th trip for reimbursement?

Yes

Enter 11th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 12th trip for reimbursement?

Yes

Enter 12th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 13th trip for reimbursement?

Yes

Enter 13th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 14th trip for reimbursement?

Yes

Enter 14th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

Would you to add a 15th trip for reimbursement?

Yes

Enter 15th Transportation Trip Info

Date

Time

One Way

Yes

Round Trip

Yes

Starting Address*

Street Address Address Line 2 City State ZIP Code

Provider Location*

Street Address Address Line 2 City State ZIP Code

Provider Name*

First Last

Purpose (i.e. Doctor, Drug Store, etc.)

Driver Info

Self

Caregiver/Private

County Operated

Other

Other - Please describe

CAPTCHA

Transportation Reimbursement Submission Request

Member Information

Driver Information

Reimbursement Details

Enter 1st Transportation Trip Info

Enter 2nd Transportation Trip Info

Enter 3rd Transportation Trip Info

Enter 4th Transportation Trip Info

Enter 5th Transportation Trip Info

Enter 6th Transportation Trip Info

Enter 7th Transportation Trip Info

Enter 8th Transportation Trip Info

Enter 9th Transportation Trip Info

Enter 10th Transportation Trip Info

Enter 11th Transportation Trip Info

Enter 12th Transportation Trip Info

Enter 13th Transportation Trip Info

Enter 14th Transportation Trip Info

Enter 15th Transportation Trip Info

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