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Get Meal Claim Form

Iowa Department of Human Services IOWA MEDICAID MEALS AND LODGING CLAIM FORM Must be sent to TMS Management Group Inc. 5800 Fleur Drive Room 231 Des Moines IA 50321-2584 This form must be completed for each trip requiring meal and/or lodging reimbursement. Claim forms with incomplete information will not be reimbursed until all information that is required is received. Receipts are required for all meals and lodging expenses. Reimbursement amounts are specified in the Iowa Medicaid Meals and Lodging Reimbursement Policy attached. Mileage is to be reported on the Mileage Reimbursement Form. Mileage is calculated as the shortest distance as calculated by MapPoint. Medicaid ID Trip Confirmation ID Number s Member Name Telephone No. Member Address City State Zip Code Name of Attendant if applicable Printed Medical Provider Name To Date s of overnight stay s From Lodging Name Cost Per night Lodging Address Number of Meals Member Signature Breakfast Cost Lunch Cost Date Dinner Cost To be completed by Physician/Medical Provider By signing below I verify that the Member s condition and/or treatment require them and attendant if applicable to incur an overnight stay s which may require additional meals and lodging expenses. Claim forms with incomplete information will not be reimbursed until all information that is required is received* Receipts are required for all meals and lodging expenses. Reimbursement amounts are specified in the Iowa Medicaid Meals and Lodging Reimbursement Policy attached* Mileage is to be reported on the Mileage Reimbursement Form* Mileage is calculated as the shortest distance as calculated by MapPoint* Medicaid ID Trip Confirmation ID Number s Member Name Telephone No* Member Address City State Zip Code Name of Attendant if applicable Printed Medical Provider Name To Date s of overnight stay s From Lodging Name Cost Per night Lodging Address Number of Meals Member Signature Breakfast Cost Lunch Cost Date Dinner Cost To be completed by Physician/Medical Provider By signing below I verify that the Member s condition and/or treatment require them and attendant if applicable to incur an overnight stay s which may require additional meals and lodging expenses. Physician and/or Medical Provider Name Signed Iowa Medicaid Provider NPI Other I certify that the above named member s medical conditions requires an attendant to accompany them during their appointments. Signed Please complete and return to TMS Management Group Inc* 5800 Fleur Drive Room 231 Des Moines IA 50321-2854 or Fax to 1-866-584-7601. If you have questions call 1-866-572-7662 during normal business hours. 470-4991 Version 1. 2 Rev* 3/11. Reimbursement amounts are specified in the Iowa Medicaid Meals and Lodging Reimbursement Policy attached* Mileage is to be reported on the Mileage Reimbursement Form* Mileage is calculated as the shortest distance as calculated by MapPoint* Medicaid ID Trip Confirmation ID Number s Member Name Telephone No* Member Address City State Zip Code Name of Attendant if applicable Printed Medical Provider Name To Date s of overnight stay s From Lodging Name Cost Per night Lodging Address Number of Meals Member Signature Breakfast Cost Lunch Cost Date Dinner Cost To be completed by Physician/Medical Provider By signing below I verify that the Member s condition and/or treatment require them and attendant if applicable to incur an overnight stay s which may require additional meals and lodging expenses. Physician and/or Medical Provider Name Signed Iowa Medicaid Provider NPI Other I certify that the above named member s medical conditions requires an attendant to accompany them during their appointments.

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