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MILEAGE REIMBURSEMENT VERIFICATION FORM Please complete this form and return it to First Transit Colorado NEMT within fourteen 14 days of the medical appointment for reimbursement. For questions please call First Transit Colorado NEMT at 855. OPS.NEMT 855. 677. 6368 or check out our web page at www. medicaidco. com/mileage. Medicaid Client Name Date of Trip Medicaid ID Appointment Time AM PM Please circle as appropriate. Medicaidco. com/mileage.

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