2. Itasca County Health Care Reimbursment Form
6. MEDICAL PROVIDER COMPLETES
8. Medical Assitance will be billed for these tickets.
   Medical Provider please verify medical appointments below.
10. Kiesler House transportation is NOT reimbursed by MA unless attending ARMHS group.
14. Name
15. PMI
17. Social Security Number
19. 1. was seen by
    (name / title of health provider)
21. Signature of Medical Provider
22. Signature Date
    Signature Date

    Signature Date
24. 2. was seen by
    (name / title of health provider)
26. Signature of Medical Provider
27. Signature Date
    Signature Date

    Signature Date
29. 3. was seen by
    (Name / title of health provider)
31. Signature of Medical Provider
32. Signature Date
    Signature Date

    Signature Date
34. 4. was seen by
    (Name / title of health provider)
36. Signature of Medical Provider
37. Signature Date
    Signature Date

    Signature Date
39. 5. was seen by
    (name / title health provider)
41. Signature of Medical Provider
42. Signature Date
    Signature Date

    Signature Date
46. RECEIPTS FROM AEOA ARE REQUIRED
48. NOTE
    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.
50. Some Qualifying Providers
    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
52. 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
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

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