MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HealthNet Spend Down Transportation Expense Log
Participant Instructions: If you wish to claim transportation costs toward your spend down, please complete and return this form to a Family Support Division office. You will need to attach a receipt or bill for the service you received, such as receipt for the prescription you picked up or the doctor appointment you kept.*
Participant Name (Please Print):	MO HealthNet Number:
Date of Service	Medical provider name, address and type of service *	Round trip distance	Who provided the transportation? Phone number	Signature of person providing transportation	Total Amount of Charge**
EX. 11/30/12	Dr. Smith, 201 Main St, Anytown MO – oncology	20 miles	John Doe 573-222-3333	John Doe	$10.00
* Attachments verifying the information above must match the dates of services listed. ** The amount you paid will not be allowed if it exceeds the state mileage rate. If this occurs, the state rate will be applied.
PLEASE COMPLETE AND SIGN ATTESTING TO THE ACCURACY OF INFORMATION PROVIDED:
Name of Person Completing Form (Please print):	Phone:
Address:
Signature of person completing form (required):
MO 886- (6-13)