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Request Ror Reimbursement Of Expenses 3921 - Oregon

Request Ror Reimbursement Of Expenses Form. This is a Oregon form and can be used in Insurer And Self Insurer Workers Comp .
 Fillable pdf Last Modified 6/18/2012
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Request for Reimbursement of Expenses Complete this form, including your workers' compensation claim number, and send it to the insurer that processes your claim. Include copies of receipts for all items except private vehicle mileage. Incomplete requests will be returned for additional information. Reimbursement must be requested within two years from date of service. Name Mailing address City P.O. Box Claim number Apt. # This is a new address ( State City Start location End location ) Phone ZIP State ZIP Doctor or hospital Trip miles Date TRANSPORTATION TOTAL miles MEALS Date Breakfast City Date Lunch City Date Dinner City $ $ $ $ $ $ $ $ $ $ TOTAL meals reimbursement LODGING Hotel/motel name Location Date Cost $ $ $ $ TOTAL lodging reimbursement PRESCRIPTIONS Name of medication Doctor Date Cost $ $ $ $ $ TOTAL prescription reimbursement By my signature, I certify that all information I have given in this request for reimbursement is true and contains no false statements or misrepresentations. TOTAL miles $ Signature of worker Date TOTAL meals, lodging, and prescription reimbursement American LegalNet, Inc. www.FormsWorkFlow.com 440-3921 (4/12/DCBS/WCD/WEB) Standard rates for the continental United States: Lodging and meal rates effective Oct. 1, 2011 Breakfast $11.50 Lunch $11.50 Dinner Lodging $23.00 $77.00 ALL private vehicle mileage effective April 17, 2012 55.5 cents per mile Previous mileage rates: 01/01/11 ­ 51.0 cents per mile 01/01/10 ­ 50.0 cents per mile 01/01/09 ­ 55.0 cents per mile 08/01/08 ­ 58.5 cents per mile Room tax is reimbursable in addition to the lodging allowance. Lodging and meal rates exceed the standard rate in the following Oregon locations: County Clackamas Clatsop Effective dates All year 10/1 ­ 6/30 7/1 ­ 8/31 9/1 ­ 9/30 10/1 ­ 6/30 7/1 ­ 8/31 9/1 ­ 9/30 All year All year 10/1 ­ 6/30 7/1 ­ 8/31 9/1 ­ 9/30 All year All year Max. lodging rate $88 $96 $131 $96 $89 $114 $89 $82 $97 $84 $105 $84 $113 $93 Meal rate* $61 $51 $51 $51 $61 $61 $61 $56 $51 $56 $56 $56 $66 $51 Deschutes Jackson/Klamath Lane Lincoln Multnomah Washington *For meals, the following percentages must be used: breakfast -- 25%; lunch -- 25%; dinner -- 50% Rates obtained from Bulletin 112. See bulletin for more information. American LegalNet, Inc. www.FormsWorkFlow.com
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