Washington > Workers Comp > Claims
Travel Reimbursement Request F245-145-000 - Washington
| Travel Reimbursement Request Form. This is a Washington form and can be used in Claims Workers Comp . |
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Mail completed forms to: Department of Labor and Industries P.O. Box 44269 Olympia, Wash. 98504-4269 Travel Reimbursement Request · · · You must have prior authorization from your claim manager. See WAC 296-20-1103. Read the instructions on the back before you start. Traveling for an Independent Medical Examination? Find the IME travel form (F245-224-000) online at www.Lni.wa.gov and click on Get a Form or Publication. Claim No. Date of injury Apt # State ZIP Social Security No. (for ID only) Phone no. Worker Information (Please print) Name (Last, First, Middle Initial) Home address (not PO Box) City Reason for travel: (check one) Medical visit or treatment Vocational services Attending retraining class (attach copy of Transportation Encumbrance form F245-375-000 signed by Vocational Counselor) Travel Information Instructions and example on back. A. B. C. D. E. F. G. Date (each trip) mm/dd/yyyy 1. 2. 3. 4. 5. 6. 7. Travel code (one per line see back of form) From (City) To (city) Provider name & reason for visit No. of miles (round trip) Expense cost (one per line) Required: Signature of the provider or office staff to verify your appointment. Date 1. Date 2. Date 3. Date 4. 7. 6. Date 5. Date Date Required: Worker's Signature These expenses are related to my worker's compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I have read and understand the instructions on the back of this form. Date Worker name printed Worker's signature F245-145-000 Travel Reimbursement Request 07-2012 American LegalNet, Inc. www.FormsWorkFlow.com Instructions: complete each column. · Column A: Date you traveled (one date per line). · Column B: Use only one code per line. Codes are listed below. · Column C: City you traveled from. · Column D: City you traveled to. · Column E: Provider you saw and reason for traveling. · Column F: Total number of miles you traveled round trip. · Column G: Dollar amount of each expense (food, lodging, fares, parking). Only one expense per line. Parking expenses under $10 don't require a receipt. You must attach copies of all receipts. All receipts must be itemized and legible. No credit card slips. Travel codes Expense Private vehicle mileage Parking Bridge & ferry toll Commercial transportation Taxi Lodging Breakfast Lunch Dinner Medical services 0401A 0402A 0403A 0405A 0414A 0406A 0407A 0408A 0409A Vocational services V0028 0402A 0403A 0405A 0414A 0406A 0407A 0408A 0409A Retraining 0301R 0302R 0303R 0304R Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Signatures Medical visits: The provider or office staff you saw must sign to verify each visit date. Vocational and Retraining services: Your Vocational Counselor must sign to verify each date you traveled. Worker's signature: You need to sign the form for reimbursement. Example A. B. C. D. E. F. G. Date (each trip) mm/dd/yyyy 1. 2. Travel code (one per line) From (City) To (city) Provider name & reason for visit No. of miles (round trip) Expense cost (one per line) 03/05/2009 03/05/2009 0401A 0402A Olympia Seattle Dr. Smith; post-op visit 120 $15.00 Need more help or more information? Go to www.LNI.wa.gov and click on Injured Worker or call 1-800-LISTENS. Or check WAC 296-20-1103. Need more forms? Go to www.Lni.wa.gov and click on Get a Form or Publication. F245-145-000 Travel Reimbursement Request 07-2012 American LegalNet, Inc. www.FormsWorkFlow.com
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