Idaho > Workers Compensation > Claim
Reimbursement Of Health Care Travel Expenses 432(1) - Idaho
| Reimbursement Of Health Care Travel Expenses Form. This is a Idaho form and can be used in Claim Workers Compensation . |
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REIMBURSEMENT FOR HEALTH CARE TRAVEL EXPENSES PURSUANT TO IDAHO CODE 72-432(1) Name of Injured Worker ____________________________________ Claim # ______________________ SSN: ____________________ Address ________________________________________________ ________________________________________________ Phone # ______________________ ______________________________ ______________ ________________________Claimants Signature Date Signed Date Received by Surety1. Use this form when claiming reimbursement for travel expenses incurred while pursuing reasonable or necessitateddiagnosis, treatment, or care of an industrial injury or occupational disease. 2. Only mileage in excess of fifteen (15) miles for any given round trip is reimburseable. However, you should report the totalmileage for each round trip. You are expected to take the shortest practical route of travel.3. Reimbursement shall be made at the mileage rate allowed by the State Board of Examiners for state employees. The currentrate for this mileage is available through your insurance company or by contacting the Idaho Industrial Commission. 4. While prompt submittal of your claim for travel reimbursement is important, you should not submit requests forreimbursement more frequently than once every 30 days. 5. YOU MUST ATTACH TO THIS FORM A COPY OF A BILL OR RECEIPT SHOWING THAT EACH VISIT OCCURRED. IC Form 432(1) IDAPA 17.02.04.321
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