Aetna Better Health of Virginia × MediDrive
Mileage Reimbursement Trip Log & Invoice
Download the official mileage reimbursement form for Aetna Better Health of Virginia Medicaid members. Get reimbursed when a friend, neighbor, or relative drives you to medical appointments.
Download Documents
Download the blank form, read the member letter with detailed instructions, and view the annotated example.
ENEnglish Documents
Download Blank Form (PDF)
The official blank form. Print, complete, and mail to claim your mileage reimbursement.
Member Letter with Instructions (PDF)
Detailed step-by-step instructions for completing and submitting the reimbursement form.
ESDocumentos en Español
Registro de Viaje de Reembolso de Millaje — Español
Guía paso a paso para enviar una solicitud de reembolso por millas recorridas.
Ejemplo Anotado en Español (PDF)
Spanish annotated example showing how to complete each field.
How It Works
Follow these steps to submit your mileage reimbursement claim.
- 1Call MediDrive BEFORE the trip to get a pre-authorized trip number.
- 2Have your friend, neighbor, or relative drive you to your medical appointment.
- 3Get the trip log signed by the physician's office at your appointment.
- 4Complete all required fields on the Mileage Reimbursement Trip Log.
- 5Mail the completed form to MediDrive Claims. Reimbursement is processed within 4–6 weeks.
Important Tips
Avoid common mistakes that can delay or deny your reimbursement.
Write down your trip number immediately!
When you call to schedule your trip, you will receive a trip number. This trip number is required on the reimbursement form. Write it down as soon as you get it — forgetting this is the most common reason for denial.
- Fill out the entire form except the "Physician/Clinician Signature" space — your doctor signs that at your appointment.
- Your doctor or counselor must sign the form as proof that you attended your appointment.
- You can list multiple trips on one form.
- Only one driver per form — if different people drive you, submit a separate form for each driver.
- Submit your completed form within 30 days of the appointment. If listing multiple appointments, the 30-day deadline starts from the earliest date on the form.
- Payment will be mailed within 4 to 6 weeks after MediDrive receives your completed form.
Required Information
Make sure these fields are completed on every form submission.
Member Information
- Member Name (as it appears on Medicaid card)
- Member ID Number
- Member Address
- Payee Name — the person who drove the member (receives the check)
Trip Log Details (one row per trip)
- Date of each trip
- Appointment time
- Pick-up address
- Drop-off address (medical facility)
- Round trip miles
- Provider/Physician signature for each trip
Attestation
The member must sign the attestation at the bottom of the form certifying that all information is true and accurate.
Form Completion Guidelines
Follow these guidelines carefully. Failure to do so may result in denial of payment.
Where to Submit
Mail or fax the completed form to the MediDrive Claims Department.
Mail To
MediDrive P.O. Box 2310 Glen Allen, VA 23058
Fax
703-951-0444Processing Time
4–6 weeks after receipt of completed form
Questions?
Mileage Claims Questions
1-833-633-4374Medicaid Reservations
1-800-734-0430FIDE Reservations
1-844-452-9375The Drive to Better Health