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Millas por un viaje de distancia razonable a la farmacia, estacionamiento, pago de peajes, transporte público y otros viajes y costos relacionados están también incluidos. Complete este formulario y adjunte los recibos. Envíe la forma original a la compañía de seguros y guarde una copia.
Mileage Worksheet for Medical Reimbursement 2023. This form allows FSA participants to request reimbursement for mileage and parking expenses incurred during medical visits. To ensure proper reimbursement, users must fill out the required information and attach evidence of mileage.
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.
If you need a medical mileage expense form for a year not listed here, please contact the Information and Assistance Unit at your closest district office of the Workers’ Compensation Appeals Board. December 2023.
This form should be used for medically related travel covered by the Federal Employees' Compensation Act and the Energy Employees Occupational Illness Compensation Program Act of 2000. For travel expenses reimbursement under the Black Lung Benefits Act (30 USC 901; 20 CFR 725.406 and 725.701) use the Form OWCP-957 Part B OMB No. 1240-0037
Medical Mileage Expense Forms | Legal Resources for Reimbursement. Due to taxes, other costs, and environmental regulations Californians pay more for gasoline. The distances North Staters must travel cause travel expenses, including gasoline costs and parking fees to add up quickly.
To help you keep a record of such expenses we have provided this form. In order to help insure that you are properly reimbursed, list each item of expense below -- whether or not you obtained a receipt (wherever possible obtain receipts).
