Medical Transportation And Travel Expense Form

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MEDICAL TRANSPORTATION AND TRAVEL EXPENSE FORM
Name _________________________________________ Month/Year ________________________________
Check List:
Check that you have attached the following documents:
Verification of Medical Appointment (s)
Recommendation for Treatment
Receipts for Parking, Meals, Accommodation
)
(if required
MILEAGE REIMBURSEMENT:
Complete the chart below for reimbursement of mileage
based on $0.20 per kilometer effective February 8, 2010
DATE
PLACE
PURPOSE
KM’s
Total Kilometers
Total Kilometers x $0.20/km (updated February 8, 2010)
OFFICE USE ONLY
Case Worker #______ Signature of CW _________________________Approved ________________________

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