CLIENT REIMBURSEMENT SHEET

Waldo County Transportation Program PO Box 130 Belfast, ME 04915 SELF DRIVE: 338-5757 338-4769 or 1-800-439-7865

Validation stamp, appointment card or physician office personnel signature required

NAME OF PERSON WITH APPOINTMENT: ____________________________________ DATE OF BIRTH: __________MAINECARE #:_____________VALID____ PHONE #:_____________ ADDRESS OF CLIENT:__ _______________________TOWN:____________ DATE OF APPOINTMENT:_________________________TIME:_______________ NAME OF DOCTOR AND MEDICAL FACILITY _____ ADDRESS OF DOCTOR:_____ TELEPHONE NUMBER:_ _____

TO: BEGINNING ODOMETER:_______________________ ENDING ODOMETER:________________________
(READING WHEN YOU LEAVE HOME OF CLIENT) (READING WHEN DROPPING CLIENT AT MEDICAL FACILITY)

FROM: BEGINNING ODOMETER:_______________________ ENDING ODOMETER:________________________
(READING WHEN LEAVING MEDICAL FACILITY) (READING WHEN DROPPING CLIENT AT HOME)

*Please attach receipts for the following covered services: TOLLS:_____________________ FERRY’S:_____________________ OTHER:_________________________ NAME AND ADDRESS OF PERSON TO BE REIMBURSED: Check here if this is a new name or address: NAME:____Patricia Kratka_________________ ADDRESS:99 Back Searsport Road, Belfast, ME 04915_____
*Print the first and last name of the person to be reimbursed the same way every time you submit a reimbursement sheet *NOTE: Reimbursement requests should be submitted weekly. Reimbursement is available for appointments made in advance. _________________________________________________________________________________________________________________________
I certify that my family has no other means of transportation available and the information above is accurate. Also, I agree to notify Waldo County Transportation of any changes in my family’s MaineCare status, income, or transportation needs. I also authorize the above medical provider to verify that I kept the above appointment when requested by the Waldo County Transportation Program. MaineCare Recipient or Responsible Adult:____________________________________________________________________________________________________ APPOINTMENT: ______________________________ RETURN: ____________________________________

Payment Authorized By

____________________________________ ______ Yes ______ No

Need appointment verification by phone

Total: _______________________________ Input Date: ___________________________

Appointment verified by ________________________ Date _________ Revised 01-21-09

INSTRUCTIONS A. Call 338-5757 and leave your appointment information on our message machine prior to going to your appointment. Be specific and make sure to leave a phone number where you can be reached. B. Have appointment verified by medical provider in the box in the upper right hand column. Attach appointment card also. C. Fill in the name of the person with appointment. D. Fill in the birth date of the person with appointment. E. Fill in the Medicaid number of the person with the appointment. F. Fill in the date MaineCare became effective. G. Fill in the client’s home telephone number. H. Fill in the address of the person with the appointment including town. I. Fill in the date and time of appointment. J. Fill in the name of the medical provider and attending physician. K. Fill in the address and telephone number of the medical provider. L. Fill in the odometer readings, beginning and ending, for each one way trip. M. Attach receipts for tolls, ferries etc, and fill in the blanks. N. Fill in the name and address of person to be reimbursed. O. A parent, guardian or MaineCare recipient must sign the form.

Medical providers will be called to verify appointments.
Submitting reimbursement forms for appointments that have not been kept is fraud, and will be reported to the Bureau of Medical Services.