Medical Mileage Expense Form
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________________________________________
_____________________________
Injured worker’s name /
Claim number / Numero de reclamo
Nombre de la persona lesionada
Medical mileage expense form
Forma de gastos por distancia recorrida por visitas medica
If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The
mileage rate is 56 cents ($.56) per mile. Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public
transportation and other travel-related costs are also included. Complete this form. Attach receipts. Send the original
to the insurance company and keep a copy. Do not send the original or a copy to the local Workers’ Compensation
Appeals Board (WCAB) or the information and assistance officer. If your travel costs are not paid within 60 days,
contact the information and assistance officer.
Si tiene que viajar para recibir tratamiento por una lesión en el trabajo, usted tiene derecho a recibir un reembolso de
$.56 por milla. Millas por un viaje de distancia razonable a la farmacia, estacionamiento, pago de peaje, transporte
público y otros viajes y costos relacionados estan tambien incluidos. Complete esta forma y adjunte los recibos. Envie
la forma original a la compañia de seguros y guarde una copia. No envie el original o la copia a la oficina local de la
Junta de Apelaciones de Compensación del Trabajador (WCAB). Si sus gastos de viajes no son pagados dentro de 60
dias, llame al oficial de información y asistencia.
Date/
Traveled from
Traveled to (include name and
Round trip
Parking/
Tolls/
Fecha
mileage/
Estacion-
Peaje
(include address)
address of doctor, hospital, therapist,
Viaje desde
Millaje viaje
etc.)
amiento
Viaje a (incluya nombre y direccion del
redondo
(incluya direccion)
medico, hospital, terapeuta, etc.)
Sample:
Sample: 1515 Maple,
Sample: Dr. Sherman, 190
Sample:
Sample:
Sample:
1/1/14
San Francisco
Oak, San Francisco
14 mi
$2.50
$
x
$.56 / mile =
$
Total miles
0.00
0
Total parking
$
0.00
Total tolls
$
0.00
Total reimbursement requested
$
0.00
Signature / Firma
Printed name / Imprima su nombre
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Parent category: Medical