Worker'S Compensation - Mileage Claim Form

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CHRISTOPHER J. SMITH, P.A.
ATTORNEY AT LAW
2805 W. Busch Blvd, Suite 219
Tampa, Florida 33618
800-886-0659
813-931-3715 Facsimile
WORKERS’ COMPENSATION - MILEAGE CLAIM FORM
List all trips to/from any authorized provider and/or the pharmacy for authorized medications.
Name:
Date of Accident:
Home Address:
Social Security #:
Home Phone:
Employer:
DATE
List trip taken below such as: Home to (name) Hospital; Home to
ROUND-TRIP
Dr. (name) and return home; Office to Dr. (name) and return home
MILEAGE
MILEAGE TIMES prevailing
IRS rate
I certify that the above information furnished by me is true and correct and,
based on such information, I hereby claim pay for the mileage as indicated.
Signature
Date

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