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Health Care Transportation Reimbursement Form

  1. Medical Provider please verify medical appointments below.

  2. (name / title of health provider)

  3. (name / title of health provider)

  4. (Name / title of health provider)

  5. (Name / title of health provider)

  6. (name / title health provider)

  7. IN EFFECT AS OF July 1, 2007, Itasca County Health and Human Services will not provide MA bus tickets directly to clients. We will reimburse clients for bus tickets purchased and used for medical transportation only. Signed documentation of medical appointments brought back to Human Services will be used to reimburse clients for the full cost of the bus tickets. Receipts from the purchase of tickets MUST be attached to the Reimbursement Form which shows 5 round trips. Bus pass receipt (25.00) must have 10 appointments documented in order to qualify for reimbursement.

  8. Chiropractors Counselors Dentists Doctors Physical Therapists EFFECTIVE 12/01/08, PHARMACY TRIPS ARE NO LONGER CONSIDERED A MA REIMBURSEABLE ACTIVITY SO PLEASE COMBINE TRIPS TO THE PHARMACY WITH OTHER MEDICAL TRIPS. THANK YOU

  9. Please bring or send fully completed reimbursement forms to the accounting window at Health and Human Services. 1209 SE 2nd Avenue, Grand Rapids MN 55744

  10. Leave This Blank:

  11. This field is not part of the form submission.