REIMBURSEMENT CLAIM FOR SPECIFIC PROGRAMS EMPLOYEE: EMPLOYEE: ** REQUIRED ** (Print) (Signature) EMPLOYEE #: PERIOD COVERED: ODOMETER RECEIPTS - Completely tabulated PRIMARY PROGRAM: SUPERVISOR: (Staple or tape to the BACK of this form) (Signature) Circle Scattered Support Subcontracting DD Case Anoka LTC Ramsey LTC Dakota LTC Hennepin LTC Managed Applicable Sites Services Management Case Case Case Case Care Program: Management Management Management Management MONTH/ MILEAGE RATE - $.43/mile (effective 5/27/18) AMOUNT CLAIMED DAY/ TO: LIST DESTINATION(S) ODOMETER MILEAGE YEAR FROM AND CLIENT INITIALS # MILES $ AMOUNT PARKING FOOD MISC. TOTAL THIS PAGE GRAND TOTAL (All Pages): $ (On last page, provide Grand Total for each column)
REIMBURSEMENT CLAIM FOR SPECIFIC PROGRAMS EMPLOYEE: EMPLOYEE: ** REQUIRED ** ODOMETER RECEIPTS - Completely tabulated (Staple or tape to the BACK of this form) (Print) (Signature) EMPLOYEE #: PERIOD COVERED: PRIMARY PROGRAM: SUPERVISOR: (Signature) Circle Applicable Program: Scattered Sites Support Services Subcontracting DD Case Management Anoka LTC Case Management Ramsey LTC Case Management Dakota LTC Case Management Hennepin LTC Case Management Managed Care MONTH/ MILEAGE RATE - $.43/mile (effective 5/27/18) AMOUNT CLAIMED DAY/ YEAR FROM TO: LIST DESTINATION(S) AND CLIENT INITIALS ODOMETER # MILES MILEAGE $ AMOUNT PARKING FOOD MISC. TOTAL THIS PAGE GRAND TOTAL (All Pages): $ (On last page, provide Grand Total for each column)
ReimbursementClaimSpptSvcsScatSites.docx