SOUTHERN ILLINOIS CARE CONNECT

TRAVEL VOUCHER

Client Name: / Month:
Date / Name of Provider/Event / Reason for Program Related Visit / Trip Origin
(Town) / Trip Destination
(Town) / Provider Verification
(must be stamped/signed by provider or note on letterhead) / Office use only!
Denied # of miles round trip

Instructions:

Complete all sections of the form. Provider verification must be signed and submitted on letterhead or stamped on this form from the providing agency. Reimbursement can be made for pre-authorized travel such as: scheduled case manager visits, program related medical visits, dental visits, mental health visits, support group/retreats and other SIHCC sponsored events.

Only one travel voucher request per month may be submitted. This completed form is due by the 10th of the following month. Late forms will not be accepted. For example, all transportation for January 1 through January 31st must be submitted by February 10th.

All documentation must be current in the client file.

Travel vouchers are available upon request pending the availability of funds and program guidelines/financial eligibility.

By signing below, I certify the above travel request is correct and represents the actual program related appointments attended.

______

Client Signature Date

Submit for to:Jackson County Health Department

Attn: Southern Illinois Care Connect

P.O. Box 307

Murphysboro, IL 62966-0307

Confidential Fax: (618)687-4933

Revised June 2015

Southern Illinois Care Connect

Travel Voucher Policy

Effective April 1, 2014

Due to Federal and State guidelines, effective April 1, 2014, mileage reimbursement is no longer allowable to be provided to the client in the form of a check.

Effective April 1, 2014 travel voucher requests will be reimbursed in the form of gas cards based on the chart below.

Miles Driven / Gas Card Amount
10-33 / $10.00
34-55 / $20.00
56-77 / $30.00
78-100 / $40.00
101-122 / $50.00
123-144 / $60.00
145-166 / $70.00
167-188 / $80.00
189-211 / $90.00
212-over / $100
  • Miles are estimated based on MapQuest city to city zip code.
  • Trips must be verified with a letter, stamp or signature by providing agency.
  • Minimum and Maximums apply ($10 min. $100 max.)
  • Gas cards will be sent by certified/restricted mail to the client with return signature receipt required.
  • Gas cards can only be used to purchase gas. Absolutely no alcohol, tobacco or firearms can be purchased with federal funds.
  • Gas cards returned undeliverable will be available for pick up in the office for 30 days. They will not be re-sent by mail. After 30 days the cards will be voided.
  • Mileage cannot be incurred for picking up undeliverable gas cards.