Logisticare mileage reimbursement wv pdf. Thank you for using gas reimbursement for your trips.
Logisticare mileage reimbursement wv pdf Here are some of the different types of Logisticare gas reimbursement options: 1. The LogistiCare Gas Mileage Reimbursement Trip Log is an essential form for individuals in South Carolina seeking reimbursement for gas mileage when traveling to medical appointments. LogistiCare administers your transportation benefit. west VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Fax #: 866-528-0462 Gas MILEAGE REIMBURSEMENT Billing Inquiries: 844-889-1942 DRIVER NAME: DRIVER PHONE #: DRIVER MAILING ADDRESS: required on the reimbursement form. LogistiCare must be notified the member is unable to sign when the reservation is scheduled. WVU-SW-PCE Archives - LISTSERV 16. 3. I hereby agree the above information is true and correct. Mileage Reimbursement -Modivcare provides mileage reimbursement to members or non-commercial drivers (i. 5 %µµµµ 1 0 obj >>> endobj 2 0 obj > endobj 3 0 obj >/ExtGState >/XObject >/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 792 612] /Contents 4 0 situations where the gas mileage reimbursement program is not an option for the member. We leverage our unique suite of solutions to address the social determinants of health (SDoH), bringing quality transportation, monitoring, chronic care management, and personal in-home assistance with activities of daily living to members. • Mileage reimbursement trips should be scheduled by calling LogistiCare’s reservation line Monday through Friday, 8:00a. Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. College Park, GA 30349 MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE FORM Must be sent to LogistiCare Inc Missouri NEMT Billing Department 503 Oak Place Ste. If you have any questions, issues or concerns, please call LogistiCare at 877-907-5186. Completed forms can be sent to: Mail: 798 Park Avenue NW, Norton, VA 24273. Show details It lets you make changes to original PDF content, highlight, black out, erase, and write text anywhere on a page, legally eSign your form, and more, all from one place. com MEMBER INFORMATION Relationship to Member Member Name Member ID SIGNATURE OF MEMBER I hereby agree the above information is true and correct. com Subject: Kansas Mileage Reimbursement (Last Name, First Name) Fax: 1-855-848-8636 7. Kansas gas mileage reimbursement trip log logistical claims department 2552 WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Fax #: 866-528-0462 Gas MILEAGE REIMBURSEMENT Billing Inquiries: 844-889-1942 DRIVER NAME: DRIVER PHONE #: DRIVER MAILING ADDRESS: CITY/STATE/ZIP: To fill out the AZ LogistiCare UHC CIP Mileage Reimbursement Trip, individuals must complete a reimbursement form, providing information about the trip, including dates, mileage driven, and the purpose of the trip, as well as submitting any required Follow these fast steps to edit the PDF Logisticare mileage reimbursement form online free of charge: West Virginia Gas Mileage Reimbursement Trip Log. Mileage reimbursement: LogistiCare may provide mileage reimbursement for eligible individuals who have to use their personal vehicles to travel to and from medical appointments. This program is for members of West Virginia Medicaid non-emergency medical transportation (NEMT) service. However, it’s not really instantly obvious how to make it polished and legally binding at the same time. eater mileage reimbursement Fill Now. Make these quick steps to edit the PDF Wv dhhr mileage reimbursement online for free: Mail or Fax to: LogistiCare Claims Department. Questions or Concerns Our Ride Assistance Line is available 24/7/365 to discuss your questions or concerns. Download your updated document, export it to the cloud, print it from the editor, or %PDF-1. It includes details required by ModivCare for processing claims. Click, don't call, to schedule your next ride. Submit the completed Driver Mileage Reimbursement Trip Log to LogistiCare via email at vaclaimsops@logisticare. 5. 1. EST. Mail completed mileage reimbursement trip log(s) to the address listed on top of the log (LogistiCare Mileage Reimbursement, 798 Park Ave, NW, Norton, VA 24273) or Fax the mileage reimbursement trip log(s) to 866-528-0462. 4. Please contact our customer service number at 1-866-796-0530, TDD 1-800-955-8770 Monday MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE Mail to: LogistiCare, 798 Park Avenue NW, Norton, VA 24273 Phone: 8669075186, Fax: 8665280462, EMail: vaclaimsops logisticare. LogistiCare's Trip Manager App is an easy way to book rides and get trip information, available for iOS and Android. claims@modivcare. MILEAGE REIMBURSEMENT FORM Send to: SoonerRide Mileage Reimbursement 2552 West Erie Drive, Suite 101 Tempe, AZ 85282-3100 WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Fax #: 866-528-0462 Gas MILEAGE REIMBURSEMENT Billing Inquiries: 844-889-1942 DRIVER NAME: DRIVER PHONE #: DRIVER MAILING ADDRESS: CITY/STATE/ZIP: WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Fax #: 866-528-0462 Gas MILEAGE REIMBURSEMENT Billing Inquiries: 844-889-1942 DRIVER NAME: DRIVER PHONE #: DRIVER MAILING ADDRESS: CITY/STATE/ZIP: MEMBER ID #: I, _____, by submitting this driver log LogistiCare Claims Department South Carolina Gas Reimbursement 1640 Phoenix Boulevard Suite 110 College Park, GA 30349 7. , please fill out the support form and we’ll reach out to you as soon as possible. *Each date of service and each leg of trip must have a physician or clinician signature in order for reimbursement to be approved. To receive mileage reimbursement the following steps must be completed: Call the reservation line, (866) 386-8331, prior to the appointment (a 5 business day notice is NOT required). Try Now! Logisticare Maine Mileage Reimbursement 2022 is not the form you're looking for? Search for another form here. Modify and eSign logisticare mileage reimbursement form to ensure exceptional communication throughout the form preparation process with airSlate SignNow. wv. The payment will be mailed within 15 days of the LogistiCare Claims Department receiving your MTM Currency is a program that provides gas mileage reimbursement (GMR) through a Focus Card™. Effective September 1, 2018, gas mileage reimbursement will be limited to the nearest medically appropriate and qualified provider not to exceed 125 miles from the member's home Fill Modivcare Mileage Reimbursement Form Pdf, Edit online. All mileage reimbursement trips are limited to 125 miles or less. Your check will be mailed, according to the schedule below. The validity of a executed document, such as the logisticare mileage reimbursement is defined by specific needs and regulations that you should comply with. Click the button below to download a free PDF reader if no PDF reader is currently installed. SIGNATURE OF MEMBER. Mail or Fax to: LogistiCare Claims A business purchase letter of intent (LOI) is sent to show the intention to buy a privately held company. 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. If you are listing more than one appointment, you must submit the completed form within 30 days from the earliest appointment LogistiCare manages and provides all of West Virginia Medicaid’s non-emergency medical transportation (NEMT) to its members. When we receive your form, we will mail your payment within 15 days. Just sign up now and you'll always be good to go. gov LogistiCare will continue to work with their current network to develop providers willing to transport COVID-19 suspected or confirmed cases in a manner that protects both the 1. sc logisticare mileage reimbursement. Mileage Reimbursement Trip Log and Invoice Instructions 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 . Thank you for using gas reimbursement for your trips. xml ¢ ( ´•ËNÃ0 E÷HüCä-Jܲ@ 5í‚Ç *Q>Àµ'Á/ÙN Ï$i#„ÒFÐv )ž¹÷ž‘£Éh²Ñ*Y Òšœ ³ IÀp+¤Yääcö’Þ mileage reimbursement. Completed forms can be sent to: Mail: 798 Park Avenue NW, Norton, VA 24273 Fax: 866-528-0462 Email: claims@modivcare. South carolina gas mileage reimbursement trip log must be sent to Mail completed mileage reimbursement trip log(s) to the address listed on top of the log (LogistiCare Mileage Reimbursement, P. situations where the gas mileage reimbursement program is not an option for the member. • Members can put up to seven (7) trips on one form. Logisticare Gas Form – Fill Out and Use This PDF. If you have any questions please call 1-866-907-5186. Revised 2018 LogistiCare Solutions LLC – Confidential & Proprietary Escorts –Providers may not charge additional fees for escort LogistiCare Claims Department Mileage Reimbursement 2552 West Erie Drive, Suite 101 Tempe, AZ 85282-3100 Email: LGTCReimbursement@logisticare. Below are five simple steps to get your south carolina gas mileage reimbursement designed without leaving your Gmail account: Handle medicaid mileage reimbursement form 2024 on any device with airSlate SignNow applications for Android or iOS and simplify any document-related process today. com. You will receive a trip number from MTM during this call. 798 Park Avenue NW. Fax: 866-528-0462. WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG. 110 . You will need PK !Z—$~„ ˆ [Content_Types]. m. All mileage reimbursement trips are limited to 125 miles or The LogistiCare Mileage Reimbursement Trip Log and Invoice Form serves as a necessary document for individuals seeking compensation for transportation Reimbursement Trip Log Instructions: • You must call MTM at 1-844-549-8353 prior to your medical appointment. o Do not lose or throw away card as all future mileage reimbursement payments will be placed on existing card. For more information, click a menu option above. Driver phone number: Contact phone number of the driver. I hereby docHub the information contained herein is true, correct and accurate. Securely download your document with other editable templates, any time, with PDFfiller. Transportation is provided for medical appointments to Schedule all your rides with just a few clicks. The easiest way to modify and eSign modivcare mileage reimbursement form 2023 effortlessly. NOTE: Each trip will be confirmed with the physician’s office before payments Complete Mileage Reimbursement Form - LogistiCare online with US Legal Forms. • LogistiCare will ONLY accept and process Mileage Reimbursement forms via HARD COPY mailed to: LogistiCare Claims Department Florida Mileage Reimbursement . Below is the current state mileage reimbursement rate. Box 248, Norton, VA 24273) Once LogistiCare has received the mileage reimbursement trip log(s), all documented information will be verified by the Claims Department. The types of transportation services and reimbursement available to your eligible Medicaid members are: 1. The payment will be mailed within 15 days of the LogistiCare Claims Department receiving your Wv Mileage Reimbursement Form With Attestation Fillable . The parties use the letter to agree on the main terms of the business purchase such as price, exclusivity period for the buyer, closing date and terms, etc. You may also email LogistiCare at gabillingops@logisticare. I have also received, read and agreed to the gas Completing the modivcare mileage reimbursement form pdf electronically is a relatively simple undertaking. w. Mileage Reimbursement Program LogistiCare will pay mileage reimbursement to a Medicaid member’s friend, relative, or guardian. •Mileage reimbursement will be received via pre-paid debit card. com DRIVER NAME:RELATIONSHIP. 1640 Phoenix Blvd. PDF Tools API. Rider rights and responsibilities while using transportation and how to contact LogistiCare. Call (844) 889 1942 for further details. 5. They include different eSignature legal guidelines, like ESIGN, UETA and eIDAS, and industry-leading data safety frameworks. MEMBER INFORMATION . Note: This form, when completed, will contain your personal Protected Health Information. Member ID Number: Enter the member identification number for reference. Designed to ensure that those who provide transportation to medical services can recover some of their expenses, this form requires mileage reimbursement trip request will not be reimbursed. billingoperations@modivcare. 18. com Revised 2018 LogistiCare Solutions LLC – Members with car in household are encouraged to transport, mileage reimbursement is offered. If you have any questions, issues or concerns, please call LogistiCare at 866-381-4853. The question arises ‘How can I design the logisticare mileage reimbursement I received right from my Gmail without any third-party platforms? ’ The answer is simple — use the airSlate SignNow Chrome extension. 1-111. People also ask mileage reimbursement form pdf. Mileage Reimbursement Form: Mileage Reimbursement Form: Mileage Reimbursement Instruction Letter: Mileage Reimbursement Instruction Letter: New Jersey Gas Mileage Attendance Verification Log: New Jersey Gas Mileage Attendance Verification Log: NJ Single Trip Request 10. This form collects essential information such as the driver's details, trip dates, and medical provider information, ensuring accurate processing of mileage reimbursements. West Virginia 25301 • 304-558-1700 • 304-558-1451 (fax) • dhhr. Complete Mileage Reimbursement Form - LogistiCare online with US Legal Forms. You A $24 gas mileage reimbursement is loaded on the Comdata card October 30. West Virginia Gas Mileage Reimbursement Trip Log WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG. Try Now! For all questions including driver safety, application status, etc. There are many benefits to MILEAGE REIMBURSEMENT GUIDELINES . City/State/ZIP: Specify the city, state, and ZIP code of the driver's address. Transportation is provided at the ambulatory and wheelchair levels of services. This website is for informational purposes only and the information is subject to change. This site is designed to provide facilities with information, phone numbers and forms you will find helpful. o Instructions and activation information will be sent with pre-paid debit card with first reimbursement payment. This is a reloadable debit card issued by U. Learn more. 550 Atlanta GA 30349 NAME RELATIONSHIP TO PARTICIPANT DRIVER MAILING ADDRESS DRIVER PHONE CITY/STATE/ZIP PARTICIPANT NAME If different from Driver IS TRIP A STANDING ORDER mileage reimbursement. Do whatever you want with a Logisticare Mileage Reimbursement Form - Fill Online : fill, sign, print and send online instantly. Easily add and highlight text, insert images, checkmarks, and symbols, drop new fillable fields, and rearrange or delete pages from your paperwork. Driver name: Full name of the driver. No software installation. Bank. Downloads : Title: Description: 2019 Mileage Reimbursement Instructions - Spanish: 2019 Mileage Reimbursement Instruction Letter - Spanish Version: Member LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 7. Your check will be mailed according to the schedule below. WEST VIRGINIA GAS MILEAGE AmeriHealth Caritas – NORTH CAROLINA MILEAGE REIMBURSEMENT TRIP LOG : Download: Healthy Blue - NORTH CAROLINA MILEAGE REIMBURSEMENT INSTRUCTIONS & TRIP LOG : Download: Healthy Blue - NORTH CAROLINA MILEAGE REIMBURSEMENT INSTRUCTIONS & TRIP LOG - Spanish : Download: United Healthcare Community Plan – NORTH CAROLINA You may fax this form to 1-855-848-8636 or email it to LGTCReimbursement@logisticare. If you can’t find an answer to your question, please don’t Below we provide guidelines for completing the Mileage Reimbursement Trip Log. Norton, VA 24273. Need Help? Our WeCare Member Experience team will help you with your feedback, questions or concerns. Email: support. West Virginia Medicaid’s non-emergency medical transportation (NEMT) to its members. Driver Phone Number: Include the phone number where the driver can be reached. No paper. – 5:00 p. 503 Oak Place Ste 503 Atlanta GA 30349 DAILY TRIP LOG Job A or B Recipient s Name A W S Per Trip Billed Amount Date of Service Total Trip Mileage Vehicle Number Last six of the VIN Will-Call Time DRIVER S NAME as it appears on driver s license Drop-off WEEK ENDING Pick-up KI BOIS Area Transit System - 9 Provider LogistiCare Claims Department South Carolina Mileage Reimbursement 798 Park Ave NW, 4th Floor Norton, VA 24273 7. You will be automatically enrolled in our Insider program, developed to enhance our commitment to you and demonstrate appreciation for the important work you do. S. g The Logisticare Mileage Reimbursement form is a document used by drivers to request reimbursement for travel costs incurred while transporting members to medical appointments. Edit your Virginia Driver Mileage Reimbursement Trip Log online. e. be ready to get more. South carolina gas mileage reimbursement trip log must be sent to: driver name: driver mailing Login to portals for members & caregivers, healthcare professionals, health services, transportation providers & brokers at Modivcare. , not a qualified transportation provider but such as a relative or family member) who transport a member to his or her Do whatever you want with a logisticare mileage reimbursement form: fill, sign, print and send online instantly. Save or instantly send your ready documents. KANSAS GAS MILEAGE REIMBURSEMENT TRIP LOG LogistiCare Claims Department 2552 West Erie Drive Suite 101 Tempe AZ 85282 DRIVER NAME RELATIONSHIP TO MEMBER DRIVER MAILING ADDRESS DRIVER PHONE CITY/STATE/ZIP MEMBER NAME If different from Driver MEMBER ID IS Learn how to integrate PDF editing, sharing, and document creation into your software. Mar 11, 2025 For more information about HMG, visit SALARY RANGE: Mileage Reimbursement. Get the Logisticare gas reimbursement schedule 2021 completed. Cancel Transportation ME Modivcare Mileage Reimbursement Trip Log 2021-2025 free printable template. Please print all required information clearly, leaving enough space between words for legibility. , Ste. Gas. Obtain michigan mileage reimbursement 2023 and click Get Form to begin. Call (844) 889-1939. Fax #: 866-528-0462. Driver mailing address: Mailing address of the driver, including City/State/ZIP. Member name: Full name of the Medicaid member. If a live person is unable to answer your call, please leave a detailed voice AmeriHealth Caritas Mileage Reimbursement Trip Log Mail claims to: Modivcare Claims Department 2552 W Erie Dr, Suite 101 Tempe, AZ 85282 Driver name: _____ Relationship to member: _____ Edit Logisticare gas reimbursement schedule 2021. Driver Mailing Address: Provide the mailing address of the driver. Failure to do so may result in denial of payment. logisticare. Easily fill out PDF blank, edit, and sign them. Key Points . Create this form in 5 minutes! Use professional pre-built templates to fill in and sign documents online faster For members who use gas mileage reimbursement, a Modivcare Gas Mileage Reimbursement Trip Log will be included in your welcome letter from Modivcare. -- 5:00p. 2. Forgetting to add this is a common mistake and will cause your reimbursement to be denied. Below we provide guidelines for completing the Mileage Reimbursement Trip Log. com Subject: OK Mileage Reimbursement (Last Name, First Name) Fax: 1-855-848-8636 7. All trips must be arranged and confirmed by ModivCare. com Feb-2021 DRIVER NAME: Modivcare has a dedicated Facilities Team to handle requests for transportation for your Medicaid clients. modivcare mileage reimbursement form pdf. Modify any field directly on the document to ensure your entries are correct. WV Mileage Reimbursement Form with Attestation. Ensure accurate completion for successful reimbursement. This information is available for free in other languages. com, fax to Complete LA LogistiCare Mileage Reimbursement Trip Log 2015-2025 online with US Legal Forms. $38,000. gov LogistiCare will continue to work with their current network to develop providers willing to transport COVID-19 suspected or confirmed cases in a manner that protects both the AvMed has contracted with LogistiCare to manage non-emergency medical transportation services (NEMT) for AvMed Medicare Circle Members. Note: This form, Fill Texas Medicaid Gas Reimbursement Form, Edit online. How It Works How to create an electronic signature for a PDF online. th. Here is a list of the most common customer questions. •Submission Methods Mail: SoonerRide Mileage State Mileage Reimbursement Rate: The State Travel Management Office announces the state mileage reimbursement rate for state employees who utilize their own vehicles for business travel. g Ambulance, as defined by Code of Virginia §32. Workers Comp Mileage Reimbursement 2021 Form Fill Out And Sign Printable PDF Template SignNow. Your West Virginia Medicaid non-emergency transportation mileage reimbursement process is about to get easier Avoid Card Fees As with any debit or credit card, you will be Mileage Reimbursementreimbursement process, please call MTM at Questions? If you have questions about the gas 1-888-513-0703. Edit this PDF using PrintFriendly's PDF editor for a seamless experience. g VA Operations Utilization Review Department 798 Park Ave NW Norton, VA 24273 STANDING ORDER FORM (Please fax to the number provided at least 48 hours before the initial trip) Mail Invoices to LogistiCare Billing Dept. After the completion of the KANSAS MILEAGE REIMBURSEMENT TRIP LOG DRIVER NAME: RELATIONSHIP TO MEMBER: DRIVER MAILING ADDRESS: DRIVER PHONE #: CITY/STATE/ZIP: MEMBER NAME (If different from Driver): MEMBER ID#: You may fax this form to 1-855-848-8636 or email it to LGTCReimbursement@logisticare. Avoid using any special characters, symbols, or non-Latin script (e. Please adhere to the guidelines provided. . It's fast and easy. MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE For questions about your claim, call 1-800-930-9060. 21: NJ Single Trip Request 10. The member withdraws $10 at an Allpoint ATM and then completes a $5 POS transaction at a Serving Patients Across All Of Florida. To make sure the *Each date of service must have a physician or clinician signature in order for reimbursement to be approved. Get Form. It helps parties understand they are on the same page concerning the acquisition of the seller’s business. Driver Name: Enter the name of the driver submitting the form. Relationship to Member Member Name Member ID . LogistiCare will reimburse mileage for non-emergency medical appointments through its Mileage Reimbursement program. Be sure to add it to your form before you forget! 2. On any device & OS. Workers Comp Mileage Reimbursement 2021 Form Fill Out And Sign Printable PDF Template SignNow For members who use gas mileage reimbursement, a LogistiCare Gas Mileage Reimbursement Trip Log will be included in your welcome letter from LogistiCare. LogistiCare WV. This form is designed for West Virginia drivers to document their gas mileage for reimbursement. I have also received, read and agreed to the We promote a collaborative work environment for Transportation Providers. WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Mileage Reimbursement Program Can a family member or friend drive you to your doctor? We have a program to pay your family member or friend for the car mileage. Create a free account and use the web to keep track of professional LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 7. 217-893-5400 fax: 271-892-4313 pleasant acres j. Please contact our customer service number at 1-866-796-0530, TDD 1-800-955-8770 Monday Mileage Reimbursement - Family, friends, and members may be eligible to receive mileage reimbursement when providing transportation to covered services. MEDICAL PROVIDER LEVEL OF SERVICE CERTIFICATION FAX# 877-457-3316 PHONE # 866-527-9945 This form is ONLY for those Patients/Members who are AMBULATORY. All trips must be arranged and confirmed by LogistiCare. 1, means any vehicle, vessel or craft that holds a valid permit issued by the Virginia Department of Health, Office of Emergency Medical Services (OEMS) and that is specially constructed, equipped, maintained and operated, and intended to be used for emergency medical care and the transportation of patients who are LogistiCare Claims Department Mileage Reimbursement 2552 West Erie Drive, Suite 101 Tempe, AZ 85282-3100 Email: LGTCReimbursement@logisticare. 21: NJ Standing Order: NJ 2019 Mileage Reimbursement Instruction Letter - Spanish Version: Member Brochure: Member Brochure : Rider rights and responsibilities while using transportation and how to contact LogistiCare. MI Logisticare Mileage Reimbursement Trip Log 2021-2025 free printable template. , Monday through Friday) you can reach a Facilities Representative by calling 1-844-889-1941 Additionally, our afterhours reservations team handles requests for urgent trips and We meet members where and when it matters, with a data-driven approach to providing care and services to best meet their needs. Complete a blank sample electronically to save yourself time and money. For routine trip requests and hospital discharges during normal business hours (8:00 a. Workers Comp Mileage Rate 2021 Georgia 2020 2022. O. The types of transportation services and reimbursement Below we provide guidelines for completing the Mileage Reimbursement Trip Log. MTM Currency: Putting You in the Driver’s Seat. Effective September, 1, 2018, gas mileage reimbursement will be limited to the nearest medically appropriate and qualified provider not to exceed 125 miles from the member's home in-state or within 30 miles of the West MILEAGE REIMBURSEMENT TRIP LOG AND INVOICE Mail to: ModivCare, 798 Park Avenue NW, Norton, VA 24273 Phone: 866-907-5186, Fax: 866-528-0462, E-Mail: Virginia. Welcome to Modivcare of Florida. Click the button below to download a free PDF reader if We provide information and forms organized by state for our facility partners at Modivcare. pdf. FSA Mileage Reimbursement Form - MedBen Sc logisticare mileage reimbursement. 8. qhghp vakf lwgaz dmgec xrunw mudsfqp sogy pfgt tsw jjulsmy tpj npif lre nwun ijzrm