Texas Facility Network

TexasFacility Network

Downloads

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 TitleDescription
Mileage Reimbursement payment scheduleThe annual payment schedule allows member’s participating in the mileage reimbursement program to determine the date of payment.
Mileage Reimbursement ProgramDescribes the process for member’s participating in the mileage reimbursement program.
Mileage Reimbursement VoucherThe required form needed for member’s participating in the mileage reimbursement program.
Texas Child Consent FormTexas Child Consent Form
Texas LOS FormTexas LOS Form
Texas Physician Transportation Restriction FormTexas Physician Transportation Restriction Form
Texas Single Trip RequestTexas Single Trip Request
Texas Standing Order FormTexas Standing Order Form
Texas Star Plus Facility BrochureExplains the processes used to request transportation through the LogistiCare Facilities department.
UHC Chip Gas ReimbursementA form required for a rider who has someone to provide transportation to the appointment. The form is completed by the rider, signed by the physician and submitted to LogistiCare for mileage/gas reimbursement.
UHC Star Gas ReimbrusementA form required for a rider who has someone to provide transportation to the appointment. The form is completed by the rider, signed by the physician and submitted to LogistiCare for mileage/gas reimbursement.
UHC Texas Chip Mileage Reimbursement FormA form required for a rider who has someone to provide transportation to the appointment. The form is completed by the rider, signed by the physician and submitted to LogistiCare for mileage/gas reimbursement.
UHC Texas Star Mileage Reimbursement FormA form required for a rider who has someone to provide transportation to the appointment. The form is completed by the rider, signed by the physician and submitted to LogistiCare for mileage/gas reimbursement.

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