CLIENT MILEAGE REIMBURSEMENT

CLIENT MILEAGE REIMBURSEMENT

Billed to Client, Reimbursed to Caregiver
This form is for mileage incurred while driving a client or running errands on behalf of a client using your personal vehicle.

These miles are reimbursed to you at $0.50 per mile and are billed and charged to the client so please log accurately.

This form is for all caregivers, regardless of hire date.
ONE TRIP PER SUBMISSION

SUBMIT CLIENT MILEAGE SAME DAY OR WITHIN 48 HOURS!

Submissions made more than 72 hours after the trip may not be approved
CAREGIVER NAME

First NameLast Name
CLIENT NAME

First NameLast Name
DATE OF TRIP

MonthDayYear
Date
NUMBER OF MILES DRIVEN TO AND FROM TRIP
PURPOSE OF TRIP
The form is ONLY for when you are driving YOUR VEHICLE FOR ERRAND OR APPOINTMENT FOR A CLIENT. Not driving to shifts. Confirm that you drove your vehicle with the client / for the client's needs?
Should be Empty: