Time the Driver dropped the IW off at the facility.

Time the IW loaded into the vehicle for the return.

Wait time must be authorized on the Authorization Confirmation document that you received from ProCare's Dispatch team in order to invoice for it. Enter the total time the driver waited at the facility.

Wait time must be authorized on the Authorization Confirmation document that you received from ProCare's Dispatch team in order to invoice for it. Enter your Per Hour rate, not the total wait time cost. Wait time must be entered separately from other fees.

Flat Rate fields should be used only if this trip was quoted as a Flat Rate on the Authorization Confirmation document you received from ProCare's Dispatch team. Do not enter mileage if invoicing a flat rate. If the service was sent at your contracted Per Mile rates, please use the Total Mileage and Per Mile Rate fields.

Enter the total loaded miles for the trip. Only enter miles driven while our passenger is in the vehicle.

Enter your contracted, or agreed upon, per mile rate. For your Contracted Per Mile rate, please refer to your Fee Schedule that was approved by Provider Relations. If you require a copy of your approved Fee Schedule please contact Provider Relations.

Other fees will include Wheelchair Load Fees, Parking Fees, Tolls, Additional Passenger fees, etc. These fees should be authorized on the Authorization Confirmation document you received from ProCare's Dispatch team. Enter the total dollar amount of the extra fees and place a breakdown in the Other Fee Details section.

Enter your total Contracted Minimum Mileage for the referral. For your Contracted Minimum Mileage, please refer to Min Trip on the Fee Schedule that was approved by Provider Relations. Multiply the Min Trip miles by the number of loaded legs on the referral. (Round Trip = Min Trip Miles x 2). If you require a copy of your approved Fee Schedule please contact Provider Relations.

This is the total dollar amount requested for reimbursement. This amount is not guaranteed and may be adjusted. If adjusted, you will receive an explanation with the reason for the change.