C:\Users\cksmith\Desktop\Copy of travel_and_expense_report_-_mflc_v3

Transcription

1 INSTRUCTIONS: >Complete below form to be reimbursed for an Magellan MFLC business related expenses >Sign and date form, note MIS# and Uni Code where applicable > form to your Magellan Supervisor for review and approval, with Subject line: <name> Expense Report <travel period> for approval Ex: John Smith Expense Report for Oct 14-Oct 20, 2012 for Approval >Magellan Supervisor will review and approve expense report form and forward form and all attachments to MFLC Finance department with I approve this expense form in the body of the . >Receipts should be scanned and attached to >For Mileage if beginning and ending odometer readings are not used, a copy of a MapQuest/Google map must be included to support # of miles to be reimbursed.

2 MAGELLAN BEHAVIORAL HEALTH MFLC TRAVEL AND EXPENSE REPORT Name: Cslr MIS# (if Applicable) Home address, City, State, Zip Phonenumber: Purpose of Trip/Expense MUST be filled in UNI Code / PMO PRO RATE DAILY Subject to GSA Limits: DATE TOTAL Hotel ( Room only) $ Baggage Handling/Housekeeping Tips $ Laundry / Dry Cleaning $ Breakfast & tips $ Lunch & Tips (Excluding Alcohol) $ Dinner & tips ( Excluding Alcohol ) $ Subtotal $ For Finance use only Less: Total GSA $ ( ) ( ) ( ) ( ) ( ) ( ) ( ) Excess Only $ *Room/Hotel Tax $ *Plane/Baggage (not paid by MGLN) $ *Train/Bus/Taxi $ Transportation Fare To/From Meals *Mileage $ $ Complete mileage log : total expense should be noted here. ----> Parking & Tolls $ Car Rental & Gas $ Telephone / Fax $ Alcohol (Associated w/ Meals ) $ Postage $ Supplies $ *Other (Please specify) $ Total Expenses $ * Detail required on page 2 1) Complete form, sign and forward to supervisor for review and approval 2) All applicable receipts must be attached and forwarded to supervisor 3) Mileage Log must be completely filled out; traveler must note beginning and ending odometer readings of POV or must provide a Mapquest/Google map of routes traveled 4) Telephone expense for overages of personal devices caused by MFLC business use must have a phone bill attached 5) Expense must be submitted w/in 30 days. ***Form and receipts can be faxed to supervisors w/ cover page requesting approval ***Form and scanned copy of receipts can be ed to supervisor w/ Subject : <name> Expense Report for Approval I hereby certify that the above expenditures are for legitimate Magellan Behavioral Health (and/or its subsidiaries) business only and include no items of a personal nature. I acknowledge that this information may be subject to the provisions of 31 U.S.C and therefore a false claim or representation made by me could result in administrative or criminal penalties against myself. I affirm that the expense incurred are consistent with the terms and performance of my Counselor Task Assignment and direction received from the cognizant supervisors. Legal Natural Payment Location Entity Account Type Dept Code AMOUNT A/P Verified TOTAL Total Expenses Deduct: Expenses Paid by MBH Deduct: Cash Advance Rec'd Counselor/Employee Signature: Date Submitted: Net Due to Employee EXPENSE RECAP For Finance Use only Net Due to Magellan (attach Check)

3 TRAVEL AND EXPENSE REPORT, pg 2 Details of Train/Bus/Taxi/Metro Fare DATE FROM TO DESCRIPTION AMOUNT Total: Details of Other: DATE FROM TO DESCRIPTION AMOUNT Total:

4 Please list all business mileage incurred by trip and attach to the Magellan Behavioral Health Expense Report for reimbursement. Time Period: MM/DD/YY Purpose of Trip Departure / Arrival Location Address, City, State MILEAGE LOG, pg 3 (using Odometer reading) Odometer Reading $0.55 Total Miles TOTAL MILES Expense Miles * Rate

5 Please list all business mileage incurred by trip and attach to the Magellan Behavioral Health Expense Report for reimbursement. Time Period: MM/DD/YY Purpose of Trip Departure / Arrival Location Address, City, State MILEAGE LOG, pg 3 (using MapQuest or Google Maps) TOTAL MILES Expense Miles * Rate $0.55 Total Miles