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DOUGLAS COUNTY MEDICAL MILEAGE ACCOUNT FOR THE MONTH Name of person transported Name of claimant providing transportation Physical Address (No P.O. Box. This form will be returned if no address listed) Address (Is this a new address?) Yes No If you want your check mailed to a P.O. Box - put P.O. Box # below: City/State/Zip Code City/State/Zip Code Social Security Number (Required) this form will NOT be processed without SSN. Telephone Number Date/Time of medical appointment REQUIRED Medical Facility (Provider) Name/Address/City/State/Zip REQUIRED This form will NOT be processed if provider address is not listed Medical Facility (Provider) Address Stamp or Signature of Physician or Assistant REQUIRED Reimbursement will be to the nearest service provider. If a specialized service at a more distant location is medically necessary, written documentation will be required from the local service provider. This agency will use Map Quest to determine Mileage For office Use Only Do not write in spaces below Verification received For office Use Only Do not write in spaces below NO PARKING WILL BE PAID For Office Use Only – do not write in this box Mileage per I hereby certify that the mileage traveled by personal automobile for which compensation is requested, was actually traveled in the service of Douglas County. Claimant’s Signature (required) Date (Attach all verification/receipts to this sheet. This sheet will be returned and will NOT be processed without Signature/Verification/SSN and Receipts (if applicable) for each visit). Return this form to: Health & Human Services, 1316 N 14th St., Suite 400, Superior, WI 54880 - Attn: Medical Transportation 7/2008-RAM FOR OFFICE USE ONLY (do not write in this box) Authorized Lodging: Meals: Mileage: Total Compensation: