<p> Trip Log Call 1-855-687-4786 (toll-free)</p><p>First Name: Last Name: Medicaid #:</p><p>Facts about Address: Phone: the passenger City: State: Zip:</p><p>Name: How is driver related to passenger: Date of Birth: Self Other: Facts about Address: Phone: the driver City: State: Zip:</p><p>Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #1 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #2 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #3 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #4 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #5 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ►</p><p>Trip Log- Revised February 1, 2013. This communication contains information that is confidential and is solely for the use of the intended recipient. It may contain information that is privileged and exempt from disclosure under applicable law. If you are not the intended recipient of this communication, please be advised that any disclosure, copying, distribution or unauthorized use of this communication is strictly prohibited. Please also notify MTM at 1-888-561-8747 and return the communication to the originating address. Signature of Participant, Parent/Guardian, or Representative: MTM, Attention Trip Logs Mail or fax I verify that the 16 Hawk Ridge Drive information on this completed ► Lake St. Louis, MO 63367 Trip Log is true. form to: Toll-free Fax: 1-888-513-1610</p><p>Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #6 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #7 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #8 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #9 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #10 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Trip #11 Healthcare Provider Name: Healthcare Provider Address:</p><p>I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Trip #12 Appointment Date: Appointment Time: Type: Round Trip One-Way Address where you were picked up: Healthcare Provider Phone: Home Other: Healthcare Provider Name: Healthcare Provider Address:</p><p>Trip Log- Revised February 1, 2013. This communication contains information that is confidential and is solely for the use of the intended recipient. It may contain information that is privileged and exempt from disclosure under applicable law. If you are not the intended recipient of this communication, please be advised that any disclosure, copying, distribution or unauthorized use of this communication is strictly prohibited. Please also notify MTM at 1-888-561-8747 and return the communication to the originating address. I certify that this patient was seen for Signature & Title of Healthcare Provider: a Medicaid-covered health service. ► Signature of Participant, Parent/Guardian, or Representative: MTM, Attention Trip Logs Mail or fax I verify that the 16 Hawk Ridge Drive information on this completed ► Lake St. Louis, MO 63367 Trip Log is true. form to: Toll-free Fax: 1-888-513-1610</p><p>Trip Log- Revised February 1, 2013. This communication contains information that is confidential and is solely for the use of the intended recipient. It may contain information that is privileged and exempt from disclosure under applicable law. If you are not the intended recipient of this communication, please be advised that any disclosure, copying, distribution or unauthorized use of this communication is strictly prohibited. Please also notify MTM at 1-888-561-8747 and return the communication to the originating address.</p>