Mileage Reimbursement Request Form printable pdf download

Mileage Reimbursement Request Form

Serviced by:

Employer's Claim Management, Inc.

P.O. Box 5614, Montgomery, AL 36103-5614

(334) 277-9395 (800) 392-1551 FAX (334) 277-5134

Employee’s Name_________________________________________________________________________

Company Name __________________________________________________________________________

Code of Alabama, 1975, Section 25-5-77 (f) requires the employer to pay mileage costs to and from medical and rehabilitation

providers at the same rate as provided by law for official state travel. All mileage is subject to verification. Claims for mileage to

a provider that is between the employee's work location and normal residence is not eligible for payment while the employee is

working. The employee has one year from the date of incurred expense to file a claim for reimbursement. Please complete and

submit this form in order to receive reimbursement.

MILEAGE REIMBURSEMENT REQUEST FORM

Employee's Name: __________________________________

Date of Incident: _____________________

Claim #: _____________________________________

Today's Date: _____________

Round Trip Mileage To and From Work: ______________________________________________________

All request should have the month, day, and year listed for each trip. Please submit forms in a timely manner.

Date of Visit

Starting

Ending

Physician/Therapist/Pharmacy

Total # of Miles

(List starting point for each destination)

Round Trip

Point

I certify the above request for mileage reimbursement to be true and correct.

Signature: ____________________________________________________

Mileage Reimbursement Request Form