Type: Appointment Date: Appointment Time: Round Trip One-Way Address where you began your trip: Healthcare Provider Phone: Home Other: Trip #6 Healthcare Provider Name: Healthcare Provider Address: Signature & Title of Healthcare Provider: I certify that this patient was seen for a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Round Trip One-Way Address you began your trip: Healthcare Provider Phone: Home Other: Trip #7 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Round Trip One-Way Address where you began your trip: Healthcare Provider Phone: Home Other: Trip #8 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Round Trip One-Way Address you began your trip: Healthcare Provider Phone: Home Trip #9 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Round Trip One-Way Address where you began your trip: Healthcare Provider Phone: Home Trip #10 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Round Trip One-Way Address where you began your trip: Healthcare Provider Phone: Home Other: Trip #11 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & of Healthcare Provider: a Medicaid-covered health service. ► Type: Appointment Date: Appointment Time: Trip One-Way Address where you began your trip: Healthcare Provider Phone: Home Other: Trip #12 Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Mail or fax MTM Signature of Participant, Parent/Guardian, or I verify that the completed form 2300 N Street NW 720 Representative: information on this on the 15th of Washington DC 20037 Trip Log is true. ► each month to: Fax: (202) 263-4642
Trip #6 Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you began your trip: Home Other: Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► Trip #7 Appointment Date: Appointment Time: Type: Round Trip One-Way Address you began your trip: Home Other: Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► Trip #8 Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you began your trip: Home Other: Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► Trip #9 Appointment Date: Appointment Time: Type: Round Trip One-Way Address you began your trip: Home Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► Trip #10 Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you began your trip: Home Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► Trip #11 Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you began your trip: Home Other: Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & of Healthcare Provider: ► Trip #12 Appointment Date: Appointment Time: Type: Trip One-Way Address where you began your trip: Home Other: Healthcare Provider Phone: Healthcare Provider Name: Healthcare Provider Address: I certify that this patient was seen for a Medicaid-covered health service. Signature & Title of Healthcare Provider: ► I verify that the information on this Trip Log is true. Signature of Participant, Parent/Guardian, or Representative: ► Mail or fax completed form on the 15th of each month to: MTM 2300 N Street NW 720 Washington DC 20037 Fax: (202) 263-4642
Smartrip-Log-DC.docx