Mileage Reimbursement Form For Cancer Treatments Or Miscellaneous Visits printable pdf download

Mileage Reimbursement Form for Cancer

Treatments or Miscellaneous Visits

Patient’s Name:__________________________________________________________________

Address:_____________________________________Phone:_____________________________

Name of Treatment Center_________________________________________________________

Address:_____________________________________Phone:_____________________________

Physicians Signature ____________________________________________________________

Please complete the dates and have this signed below. The purpose of this form is to apply

for reimbursement for any mileage accumulated during trips for cancer related needs, such

as radiation and/or chemotherapy treatment, MD appointments, labs, tests, etc. Patient does

not need to track mileage, MapQuest will be used from patient’s address to treatment

center, please provide full address for both and use a different form for each doctor or

treatment center. Please submit at least quarterly for payment

Date

Treatment Center Signature

Date

Treatment Center Signature

(Can be signed by nurse)

__________ _______________________ __________ _________________________

Please return form to:

The Putnam County Cancer Assistance Program

1800 N Perry St, Suite 103

Ottawa, OH 45875

419-235-6487 / 419-538-6482

Fax: 419-943-1040

Revised 01/2017

A United Way Member Agency, United Way of Putnam County

Mileage Reimbursement Form For Cancer Treatments Or Miscellaneous Visits