Medical Mileage Reimbursement Form

Medical Mileage Reimbursement Form
If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The mileage rate is .56 cents ($0.56) per mile. Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel-related costs are also included. Complete this form. Attach receipts. Send the original to the insurance company and keep a copy. Do not send the original or a copy to the local Workers’ Compensation Appeals Board (WCAB) or the information and assistance officer. If your travel costs are not paid within 60 days, contact the information and assistance officer. Enter the information below to calculate your mileage reimbursement.
Injured Worker's Name *
First & Last Name
1. CLICK HERE TO DOWNLOAD THE FORM
2. FILL OUT THE MILEAGE FORM YOU DOWNLOAD ON YOUR PHONE, TABLET, COMPUTER OR LAPTOP
  (YOU CAN PRINT THE FORM FILL IT OUT BY HAND, BUT YOU WOULD NEED A SCANNER TO UPLOAD)
3. SAVE YOUR COMPLETED FORM WITH CHANGES
4. UPLOAD THE COMPLETED FORM BELOW :
File Upload - UPLOAD COMPLETED MILEAGE FORM

INSERT COMPLETED MILEAGE FORM HERE
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IF ANY Kindly attach the PDF or JPG file of the PARKING /TOLL receipts here:

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Date*

MonthDayYear
Claim Number
Email*
enter e-mail incase you want to finish the form later
Coverage Start Date

MonthDayYear
Coverage End Date

MonthDayYear

Mileage Information*

	Date	Traveled From (include address)	Traveled To (include name and address of Dr)	Round trip mileage	Parking Fee	Toll Fee
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