Medical Mileage Expense Form (For Travel On Or After 7-1-22) | Pdf Fpdf Docx | California

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Medical Mileage Expense Form (For Travel On Or After 7-1-22) | Pdf Fpdf Docx | California

Last updated: 6/24/2022

Medical Mileage Expense Form (For Travel On Or After 7-1-22)

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Description

MEDICAL MILEAGE EXPENSE FORM (FOR MILEAGE AFTER 07/01/2022). This is a bilingual (English/Spanish) California workers’ compensation reimbursement form used by injured workers to claim travel expenses related to medical treatment. The form allows claimants to record dates of travel, start and end locations, round-trip mileage, parking fees, bridge tolls, and other approved travel costs. Reimbursement is calculated at the state-mandated rate of 62.5 cents per mile for reasonable travel, including trips to pharmacies. Claimants must attach receipts, keep a copy, and submit the original to the insurance carrier. The form also includes the fraud warning required under California law and provides a section for claimant signature and totals. www.FormsWorkflow.com

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