New York > Workers Compensation
Claimants Record Of Medical And Travel Expenses C-257 - New York
| Claimants Record Of Medical And Travel Expenses Form. This is a New York form and can be used in Workers Compensation . |
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State of New York WORKERS' COMPENSATION BOARD CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT CLAIMANT'S NAME WCB CASE NO. SOCIAL SECURITY NO. RESIDENTIAL ADDRESS MAILING ADDRESS (IF DIFFERENT) In connection with the above workers compensation case, you are entitled to be reimbursed for (1) drugs, crutches or any apparatus properly prescribed by your doctor and for (2) fares, automobile mileage or other necessary expenses going to and from your doctor's office or the hospital. 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). Submit the completed form and copies of all receipts or bills to the workers' compensation insurance carrier (or to your employer, if self-insured) and to the Workers' Compensation Board. (See Board addresses on reverse.) It is suggested that you retain a copy of the receipts and bills for your records. En relación con el caso de compensación para trabajadores antes mencionado, usted tiene derecho a recibir un reembolso por (1) medicamentos, muletas o cualquier aparato indicado como corresponde por su médico y (2) tarifas, millaje de automóvil u otros gastos necesarios para trasladarse desde y hasta el consultorio de su médico u hospital. Le proporcionamos este formulario para ayudarlo a llevar un registro de esos gastos. Con el objetivo de garantizar que usted reciba el reembolso correspondiente, enumere cada ítem de gasto a continuación, tenga o no un recibo por ese gasto (siempre que sea posible, intente obtener un recibo). Envíe el formulario completo y copias de todos los recibos o facturas a la compañía de seguros de compensación para trabajadores (o a su empleador en caso de que tenga un seguro propio) y a la Junta de Compensación para Trabajadores (Workers' Compensation Board). (Consulte las direcciones de la Junta en el reverso). Le sugerimos que guarde una copia de los recibos y facturas para sus registros. NATURE OF EXPENSE / TIPO DE GASTOS DATE / FECHA AMOUNT / CANTIDAD Continue on Reverse. C-257 (9-10) - Sigue al dorso. THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. LA JUNTA DE COMPENSACIÓN OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR. American LegalNet, Inc. www.FormsWorkFlow.com NATURE OF EXPENSE / TIPO DE GASTOS DATE / FECHA AMOUNT / CANTIDAD 100 Broadway State Office Building Menands 44 Hawley Street 369 Franklin Street 130 Main Street W. 935 James St. ALBANY 12241 BINGHAMTON 13901 BUFFALO 14202 ROCHESTER 14614 SYRACUSE 13203 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 (866) 750-5157 (866) 802-3604 (866) 211-0645 (866) 802-3730 (866) 211-0644 DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Line: 877-533-0337 Address for Email Filing: wcbclaimsfiling@wcb.state.ny.us C-257 (9-10) Reverse American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.state.ny.us
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