Form 25T – Fill Out and Use This PDF

The 25T form is an essential document for employees in North Carolina seeking reimbursement for travel expenses related to medical treatment under the Workers' Compensation Act. It outlines the necessary information and requirements for claiming reimbursement, including mileage rates and specific conditions for overnight stays and meals. For those eligible, understanding and properly completing this form can significantly ease the financial burden of travel for medical care. Ensure your reimbursement is processed smoothly by clicking the button below to fill out the 25T form.

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Form 25T PDF Details

In the realm of workers' compensation, navigating the maze of paperwork and protocols is a task that many find daunting. Among the myriad forms that employees may encounter is the 25T form, a document mandated by the North Carolina Industrial Commission under the provisions of the Workers' Compensation Act. This form plays a pivotal role in ensuring that employees are reimbursed for travel expenses incurred while receiving medical treatment for a work-related injury. Specifically, it entitles employees to a reimbursement rate of $0.58 per mile for travel distances of 20 miles or more roundtrip, effective from January 1, 2019. The form outlines provisions for special consideration towards employees who are totally disabled and specifies that no reimbursement is available for travel for the sole purpose of purchasing medication or supplies, except under medically necessary circumstances. Additionally, the 25T form provides a structure for claiming reimbursement for other expenses related to overnight stays, meals, parking, and cab fares, with the stipulation that receipts must be submitted for these expenses. It also includes a section for the employee to certify the incurrence of these expenses due to their workers' compensation injury and clarifies the process for submission and payment of the claim. Through this form, the North Carolina Industrial Commission aims to streamline the process of claiming travel-related reimbursements, ensuring that injured employees are not burdened with the financial costs of seeking medical treatment.

Question	Answer
Form Name	Form 25T
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	form 25t nc industrial commission, nc form 25t, form 25t, nc industrial commission form

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NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #

ITEMIZED STATEMENT OF CHARGES FOR TRAVEL

Emp. Code #

Carrier Code #

Carrier File #

The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act

Employer FEIN

Employee’s Name

Address

CityState Zip

(	)	-	(	)	-
Home Telephone				Work Telephone

			(	)	-
Employer's Name			Telephone Number

Employer’s Address			City	State	Zip

Insurance Carrier

Carrier's Address			City	State	Zip
(	)	-	(	)	-
Carrier's Telephone Number				Fax Number

Employees are entitled to reimbursement of $0.58 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting January 1, 2019. 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).

						TOTAL MILES
DATE			NAME OF MEDICAL PROVIDER		CITY	ROUNDTRIP
/	/
/	/
/	/
/	/
/	/
		If overnight		Total motel expense (actual, up to $71.20 per	Total Miles:
		If overnight		Total motel expense (actual, up to $71.20 per
		stay is		day in-state or $84.10 per day out-of-state):
		necessary, the
OTHER		following items		Total meal expense ($8.40 Breakfast, $11.00 Lunch,	X [mileage rate]*
OTHER		will be		and $18.90 in-state or $21.60 out-of-state Dinner):
EXPENSES		will be		and $18.90 in-state or $21.60 out-of-state Dinner):
EXPENSES		approved as			Other expenses:
		approved as
		submitted.		Total parking & cab expense (actual charge):
		submitted.
		(Receipts must
		(Receipts must
		be furnished for		Total for other expenses:	Total all expenses:
		carrier’s file.)		Total for other expenses:
		carrier’s file.)

*Prior mileage rates are as follows: (a) $0.545 for 2018; (b) $0.535 for 2017; (c) $0.54 for 2016; (d) $0.575 for 2015; (e) $0.56 for 2014

I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury.

Employee signature		Carrier’s approval
Employee:		Employer or Carrier/Administrator:
Mail your bill in duplicate promptly to employer and/or		Travel may be reimbursed directly to the employee. It is
insurance carrier		not necessary to submit bills to the Commission for
		approval. Pay and retain copy in carrier's file.

	NOTICE TO INJURED EMPLOYEE:
	THIS FORM SHOULD BE RETURNED TO THE CARRIER
FORM 25T	AT THE ADDRESS ABOVE FOR PAYMENT.
01/2019

PAGE 1 OF 1

FORM 25T

FOR ASSISTANCE, CALL:

N.C. INDUSTRIAL COMMISSION

MAIN TELEPHONE: (919) 807-2500

HELPLINE: (800) 688-8349

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north carolina industrial commission form 25t writing process described (stage 1)

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The way to complete north carolina industrial commission form 25t portion 2

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Form 25T – Fill Out and Use This PDF

Form 25T PDF Details

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