Free 50254.pdf - Indiana

REIMBURSEMENT FOR TRAVEL TO/FROM APPROVED PROVIDER(S) FOR 50 MILES OR MORE ROUNDTRIP
State Form 50254 (R/12-03) Form approved by State Board of Accounts, 2003

INSTRUCTIONS 1. All sections completed, printed, and legible. 2. Signatures must be original in ink. 3. Maximum of three (3) travel dates per form. 4. One year filing limit from date of travel. 5. Return to CSHCS.

INDIANA STATE DEPARTMENT OF HEALTH CHILDREN'S SPECIAL HEALTH CARE SERVICES (CSHCS) 2 NORTH MERIDIAN STREET INDIANAPOLIS, INDIANA 46204

PARTICIPANT INFORMATION
Name of Child

Date of Birth (month, day, year)

COMPLETED BY PARENT/GUARDIAN
CSHCS #

Street address of participant (number and street, city, state, ZIP code (spell city name completely)

TRANSPORTATION INFORMATION

Date(s) of Travel (month, day, year & maximum of three per claim) To (number and street, city, state, ZIP code (spell city name completely) Reason(s) for Visit(s) Name of Driver Driver's Date of Birth

COMPLETED BY PARENT/GUARDIAN/DRIVER

Driver's License # (provide copy if not Indiana) Vehicle Plate # (provide copy of registration if not Indiana)

MEDICAL PROVIDER INFORMATION
Name of Medical Provider (printed) Signature of Medical Provider (must be in ink)

COMPLETED BY MEDICAL PROVIDER
Date (month, day, year)

PARENT/GUARDIAN INFORMATION
Name of Parent/Guardian (printed) Signature of Parent/Guardian (must be in ink)

Mailing address of parent/guardian, if different from above (number and street, city, state, ZIP code (spell city name completely)

COMPLETED BY PARENT/GUARDIAN

Date (month, day, year)

I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has been paid.