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Department of Disability and Aging-Transportation
Month/Year
*
Travel for the approved recipient will be reimbursed at either the state or agency mileage, whichever is lower. This form is used for travel for medical or nonmedical appointments (day services and other related activities).
Mileage - The amount will be calculated by the agency staff utilizing point to point mileage.
Meals - Receipts for the recipient are required.
Lodging - Receipts for the recipient are required.
Person Supported Name:
*
County:
*
Department of Disability and Aging - Transportation
*
Rows
Date
Place Left
Time Left AM/
Place Arrived
Arrival Time AM/PM
Miles
TOTAL
1
2
3
4
5
6
7
8
9
GRAND TOTAL
*
By signing and dating this Transportation Form, I, the person supported or legal representative, indicate that all of the information above is correct.
Signature of Person Supported or Legal Representative
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
All recipients of the Family Support Program sign an annual Service Plan with the agency.
The Service Plan documents the service and amount approved for the year. This Reimbursement Form is to reimburse you for the approved travel.
DIDD-5199
RDA Pending
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