CSHCS Transportation Request

*NOTE: CSHCS does NOT reimburse Medicaid enrolled clients for transportation. If you/your child have Medicaid/Medicaid Health Plan, please contact your health plan’s beneficiary line for reimbursement help.

*CSHCS provides transportation reimbursement for travel to appointments with authorized providers on your/your child’s account. Reimbursement will only be processed if a request is made within 90 days from the date of the appointment. Your signature will be required, and you will have to return the form to CSHCS staff for submission. Please note that reimbursement checks may take several months to be issued by the state.

*Out of State travel reimbursement – Out of State travel reimbursement for CSHCS related appointments may be available and must be made PRIOR to the appointment. Please call 1-800-359-3722 for assistance.

1. Client Name *This question is required.

2. Date of Birth *This question is required.

3. CSHCS ID # *This question is required.

4. Email *This question is required. This question requires a valid email address.

5. How many visits do you need to submit travel for? *This question is required. This question requires a valid number format.