Itemized Statement Of Charges For Travel {25T} | Pdf Fpdf Doc Docx | North Carolina

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Itemized Statement Of Charges For Travel {25T} | Pdf Fpdf Doc Docx | North Carolina

Itemized Statement Of Charges For Travel {25T}

This is a North Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 3/30/2016

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North Carolina Industrial Commission IC File # ITEMIZED STATEMENT OF CHARGES FOR TRAVEL The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Emp. Code # Carrier Code # Carrier File # Employer FEIN ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City City ) - Telephone Number State Zip ( ) - ( ) State Zip Home Telephone Work Telephone ( ) - ( ) - Carrier's Telephone Number Fax Number Employees are entitled to reimbursement of $0.54 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting January 1, 2016. Special consideration will be given to employees who are totally disabled. No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers (G.S. §97-25). DATE / / / / / / / / / / NAME OF MEDICAL PROVIDER CITY TOTAL MILES ROUNDTRIP OTHER EXPENSES If overnight stay is necessary, the following items will be approved as submitted. (Receipts must be furnished for carrier's file.) Total motel expense ($45.00 per day): Total meal expense ($6.00 Breakfast, $8.00 Lunch, and $14.00 Dinner): Total parking & cab expense (actual charge): Total for other expenses: Total Miles: X [mileage rate]* Other expenses: Total all expenses: *Prior mileage rates are as follows: (a) $0.575 for 2015; (b) $0.56 for 2014; (c) $0.565 for 2013; (d) $0.555 for July 1, 2011 - December 31, 2012; (e) $0.51 for January 1, 2011 - June 30, 2011; (f) $0.50 for 2010; (g) $0.55 for 2009; (h) $0.585 for July 1, 2008 - December 31, 2008; (i) $0.505 for January 1, 2008 - June 30, 2008; (j) $0.485 for 2007; (k) $0.445 for January 18, 2006 - December 31, 2006; and (l) $0.31 for travel before January 18, 2006. I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury. Employee signature Employee: Mail your bill in duplicate promptly to employer and/or insurance carrier Carrier's approval Employer or Carrier/Administrator: Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval. Pay and retain copy in carrier's file. FORM 25T 12/2015 PAGE 1 OF 1 FORM 25T FOR ASSISTANCE, CALL: N.C. INDUSTRIAL COMMISSION MAIN TELEPHONE: (919) 807-2500 WORKERS' COMPENSATION INFORMATION SPECIALISTS: (800) 688-8349 American LegalNet, Inc. www.FormsWorkFlow.com

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