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Injured Worker Statement Reimbursement Of Travel Expense BWC-1178 - Ohio
| Injured Worker Statement Reimbursement Of Travel Expense Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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· List travel dates in chronological order. Example Help prevent delays in reimbursement Correct month/day/year Completing the Injured Worker Statement for Reimbursement of Travel Expense BWC pays reimbursements in 4 and 6 based on the rate effective at the time of travel. Rates are subject to change every year. If you have any questions regarding the rates, please contact the customer service office listed on the front of the form. 1. DATE 2. Incorrect month/day/year DATE 1/4/2008 1/17/2008 1/31/2008 1/31/2008 1/4/2008 3/17/2008 · Submit this form immediately after your trip or as soon as you have filled the travel lines. 1. 2. 3. 4. Injured worker information - Complete. Date of travel - Enter month, day and the year that you traveled to receive service. Travel - Indicate the cities you traveled from and to. Use only one from and to box per round trip. Total car mileage per trip - Enter the amount of miles traveled to your destination each day. The distance must be greater than 45 miles round trip per day. BWC must authorize mileage in excess of 400 miles round trip in advance. b. In-state meals: Enter the actual amount. You must travel a minimum of 100 miles one way to receive reimbursement for meals. Reimbursement applies to injured worker only. BWC will reimburse companion expenses only if it authorized companion travel in advance. Out-of-state meals: BWC will reimburse for meals per day, not to exceed the current maximum rate. Reimbursement applies to the injured worker only. BWC will reimburse companion expenses only if it authorized companion travel in advance. c. In-state lodging: Enter the actual amount. BWC must authorize lodging in advance. BWC will pay reimbursement not to exceed the current maximum rate on the date of travel. Receipts will be required. Out-of-state lodging: BWC will reimburse for a commercial establishment at reasonable actual cost. 7. Reason for travel Please indicate the reason you are requesting travel reimbursement by checking one of the options. If you check Employer scheduled exam, please submit this request form to your employer for reimbursement. Signature and date - Sign your full name and the date you completed this form. NOTE: When requested to appear for a medical examination by a physician of the employer's choice, there is no minimum mileage restriction for car mileage reimbursement. Submit the travel expense statement form to the employer. 5. Other types of travel/Out-of-state travel - This includes travel by bus, taxi, train, air or other special transportation that is greater than 45 miles round trip. BWC must authorize such travel in advance. Reimbursement applies to injured worker only. BWC will reimburse companion expenses only if it authorized companion travel in advance. BWC requires receipts and reimburses for actual fare. a. Type: Enter the type of transportation used. b. Cost: Enter the cost of transportation used. 6. Other expenses - Includes miscellaneous, meals, and lodging. a. Miscellaneous: Enter expenses for parking and tolls only. BWC requires receipts and will pay reimbursement for the actual amount. NOTE: 8. If you are an injured worker employed by a self-insuring employer, complete this form and return it to your employer. American LegalNet, Inc. www.FormsWorkFlow.com Injured Worker Statement for Reimbursement of Travel Expense Prevent delays in reimbursement · List travel dates in the order you took trips. · Submit this form immediately after your trip or as soon as you complete the travel lines. · Type or print lines 1-7, sign line 8. 1. Last name Street address or P.O. box City 2. Date month/day/year From To From To From To From To From To 7. 8. Check reason for travel: BWC scheduled exam IC scheduled exam MCO scheduled exam Employer scheduled exam Pre-authorized specialized treatment Vocational Rehabilitation 3. Travel State 4. 3 Total car mileage per trip Nine-digit ZIP code 5. a. First Return completed form to: M.I. Claim number Social Security number Telephone number ( 6. ) Other expenses b. Meals c. Lodging Other types of travel b. Costs Type a. Misc. I, the injured worker, certify the statements made on this travel expense statement are true, and that all expenditures were used for the travel expenses indicated. Signature: Date: I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC, or who knowingly accepts payment to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Official use only Check only if charged to Surplus Fund BWC W0501 - Travel & Misc. W0502 - Meals W0503 - Lodging $ $ $ Sub total Total meals 6b. Total lodging 6c. Total amount to be reimbursed Official approval signature $ $ $ $ Date Telephone number ( ) User name (A#) Procedure codes Industrial Commission of Ohio W0515 - Travel and Misc. W0516 - Meals W0517 - Lodging Amount (rate per mile) Code Rehabilitation W0600 - Travel and Misc. W0601 - Meals W0602 - Lodging TCN Mileage, meals and lodging calculations Total car mileage 4. Total other types of travel 5b. Total miscellaneous 6a. X BWC-1178 (Rev. 9/22/2010) Distribution: BWC claim file, injured worker American LegalNet, Inc. www.FormsWorkFlow.com s s C-60
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