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The mileage rate is 65.5 cents ($0.655) 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.
Complete este formulario y adjunte los recibos. Envíe la forma original a la compañía de seguros y guarde una copia. No envíe el original o la copia a la oficina local de la Junta de Apelaciones de Compensación del Trabajador (WCAB).
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.
Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel-related costs are also included. Complete this form.
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.
Medical Mileage Expense Form 2023 For mileage that occurs in 2023, the rate is 65.5 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.
Rates Change Regularly. Mileage reimbursement rates vary depending on when you have traveled. Per the Labor Code, “it is dependent upon the mileage rate adopted by the Director of the Department of Personnel Administration pursuant to Section 19820 of the Government Code, whichever is higher, plus any bridge tolls.”
