Mileage Expense Certification Log Template printable pdf download

Mileage Expense Certification Log Template

Mileage Expense Certification Log

You may use this form to itemize mileage expenses necessary to obtain eligible medical care.

Please note: the total from this page must be transferred to a completed and signed claim form

and this Mileage Log must be submitted with your claim form as supporting documentation.

# of round

Name of provider of eligible medical service/

Date(s) of

trip miles

Where service was provided

Reason for/type of service

service

traveled

Mileage expense*

0.00

Total (transfer this total to your claim form and submit log with your claim form)

* The mileage rate for services provided:

on or after 1/1/2017: 17 cents x # of miles.



from 1/1/2016 - 12/31/2016: 19 cents x # of miles.



I hereby certify that an amount equal to the amount set forth above was expended by me on the dates set forth above for

mileage expenses incurred while traveling to/from a provider of eligible medical services.

Employee Name: ______________________________________________ Member ID: __________________________

(Please print clearly)

Name of Employer: __________________________________________________________________________________

(Please print clearly)

Employee Signature: _________________________________________________________

Date: ________________

01/2017

Mileage Expense Certification Log Template