Form E3065 PDF Details

The E3065 form plays a crucial role for individuals who have suffered an industrial injury and are seeking reimbursement for their medical travel expenses. It is specifically designed to streamline the process of claiming costs related to visits to medical practitioners, pharmacies, and other related travel expenditures such as parking and public transportation. The form requires claimants to detail their travel dates, destinations, and expenses, while also adhering to the mileage rate provided, which varies by year. For instance, the rate for 2022 is distinct from previous years, reflecting changes in costs over time. Additionally, the form emphasizes the importance of honesty in the claim process, warning that presenting false information is a serious offense, potentially resulting in fines or imprisonment. It is a tool not only for facilitating financial reimbursement but also for maintaining integrity within the compensation system. Designed to be submitted to the State Compensation Insurance Fund, claimants must attach any relevant receipts to support their claims, ensuring a thorough record of their expenses. This form serves as a vital document in managing the aftermath of workplace injuries, ensuring that individuals are fairly compensated for their travel costs while recovering.

Form NameForm E3065
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesscif mileage form, e3065, scif medical mileage expense form, fund mileage form

Form Preview Example

Please mail to your assigned claims adjuster provided on your claim correspondence or mail to one of these State Fund Claims Processing Centers:

P.O. Box 65005 Fresno, CA 93650

P.O. Box 3171 Suisun City, CA 94585

Clear Form

Injured's Name / Nombre de la Persona Lesiónada

Claim Number / Número de Reclamo

Medical Mileage Expense Form

Forma de Gastos por Distancia Recorrida por Visitas Médica

You are entitled to reimbursement of medical travel expense incurred because of your industrial injury. Complete this form to request reimbursement of medical travel expense. Mileage rates are different depending on the day you traveled. We will calculate the total due using the miles traveled. Please see example below. California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Please note: Mileage for reasonable travel to the pharmacy, parking, bridge tolls, and public transportation costs should also be included. Attach receipts and send this form to State Compensation Insurance Fund. Keep a copy for your records.

Rate For Travel / Tarifa Para Viajes

01/01/2022 - Current

58.5 cents/centavos

01/01/2016 - 12/31/2016

54.0 cents/centavos

01/01/2021 - 12/31/2021

56.0 cents/centavos

01/01/2015 - 12/31/2015

57.5 cents/centavos

01/01/2020 - 12/31/2020

57.5 cents/centavos

01/01/2014 - 12/31/2014

56.0 cents/centavos

01/01/2019 - 12/31/2019

58.0 cents/centavos

01/01/2013 - 12/31/2013

56.5 cents/centavos

01/01/2018 - 12/31/2018

54.5 cents/centavos

07/01/2011 - 12/31/2012

55.5 cents/centavos

01/01/2017 - 12/31/2017

53.5 cents/centavos

01/01/2011 - 06/30/2011

51.0 cents/centavos

Usted tiene derecho a recibir reembolso por gastos de viaje por visitas médicas incurridos debido a la lesión sufrida en el trabajo. Llene este formulario para solicitar el reembolso de gastos de viaje médicos. Las tarifas para millaje son diferentes según el día que usted viajó. Vamos a calcular el total adeudado usando las millas que usted viajó. Por favor, vea el ejemplo abajo. Las leyes de

California establecen que la siguiente declaración aparezca en este formulario: Cualquier persona que a sabiendas presente reclamos falsos o fraudulentos para el pago de una pérdida, será culpable de un delito y se le podría multar y encarcelar en la penitenciaría estatal.

Por favor de notar: Millaje razonable para viajar a la farmacia, aparcamiento, peajes de puentes, los costos del transporte público también debería incluirse. Adjuntar recibos y envíe este formulario a State Compensation Insurance Fund. Guarde una copia para sus archivos.

Date /

Traveled from


Traveled to (include name and address of


Round trip

For State Fund


(include address)


doctor, hospital, therapist, etc.)





Viaje desde


Viaje a (incluya nombre y dirección del


Millaje de Ida y



(incluya dirección)


medico, hospital, terapeuta, etc.)





1515 Maple,


Dr. Sherman, 190 Oak,



14 mi x 58.5 c




14 mi

San Francisco


San Francisco


= $ 8.19

















































































































Total Parking and/or Tolls (attach receipts)







Estacionamiento y/o Peaje (incluya recibos)









Total Public Trans / Other








Transporte Público / Otros Total















































e3065 (Rev. 12/21)

How to Edit Form E3065 Online for Free

The form e3065 filling out course of action is quick. Our software lets you work with any PDF file.

Step 1: Get the button "Get Form Here" and select it.

Step 2: You are now able to modify form e3065. You possess plenty of options with our multifunctional toolbar - you can include, erase, or change the content material, highlight the particular components, and perform several other commands.

The next areas are included in the PDF form you'll be creating.

example of gaps in state fund mileage form

Provide the necessary data in the Example Ejemplo, Maple San Francisco, Dr Sherman Oak San Francisco, mi x c, Total Parking andor Tolls attach, Total Public Trans Other, SIGNATURE FIRMA, PRINT NAME IMPRIMA SU NOMBRE, DATE FECHA, e Rev, and TOTAL REIMBURSEMENT area.

step 2 to entering details in state fund mileage form

Step 3: Choose the Done button to save your form. At this point it is obtainable for export to your device.

Step 4: To prevent different hassles in the foreseeable future, be sure to generate up to two or three duplicates of the file.

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