I A Mileage Form PDF Details

Traveling for medical treatment following a work-related injury can come with significant expenses, from gas to parking fees. Recognizing this, the I A Mileage form serves as a vital tool for injured workers seeking reimbursement for travel costs incurred while receiving necessary medical care. The form allows injured workers to claim a mileage reimbursement rate of $0.56 per mile, covering not only the distance to and from medical providers but also reasonable expenses related to parking, tolls, and public transportation. It is crucial for injured workers to complete this form accurately, attach all relevant receipts, and submit it to their insurance company while retaining a copy for their records. It's important to note that this form should not be sent to the local Workers’ Compensation Appeals Board (WCAB) or the information and assistance officer. Furthermore, if reimbursement is not issued within 60 days, it's recommended that the injured worker contacts the information and assistance officer. This process, legislated by California law, emphasizes the necessity of honesty in reporting travel expenses, as presenting false or fraudulent claims is a criminal offense that may result in fines or imprisonment. Through the I A Mileage form, injured workers have a structured way to ensure they are not out-of-pocket for the essential travel costs associated with their recovery and treatment.

QuestionAnswer
Form NameI A Mileage Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesi a mileage form 2021, medical form mileage, california medical mileage, mileage form 2021

Form Preview Example

________________________________________

________________________________

Injured worker’s name /

Claim number / Número de reclamo

Nombre de la persona lesionada

 

M e d ica l m ile a g e e x p e n se f or m

Formulario de gastos de viajes para asuntos médicos

If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The mileage rate is .56 cents ($0.56) per mile. Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel-related costs are also included. Complete this form. Attach receipts. Send the original to the insurance company and keep a copy. D o n ot send the original or a copy to the local Workers’ Compensation Appeals Board (WCAB) or the information and assistance officer. If your travel costs are not paid within 60 days, contact the information and assistance officer.

Si tiene que viajar para recibir tratamiento por una lesión en el trabajo, usted tiene derecho a recibir un reembolso de .56 centavos ($0.56) por milla. Millas por un viaje de distancia razonable a la farmacia, estacionamiento, pago de peajes, transporte público y otros viajes y costos relacionados están también incluidos. Complete este formulario y adjunte los recibos. Envíe la forma original a la compañía de seguros y guarde una copia. No envíe el original o la copia a la oficina local de la Junta de Apelaciones de Compensación del Trabajador (WCAB). Si sus gastos de viajes no son pagados dentro de 60 días, llame al representante de información y asistencia.

D a t e /

Tr a v e le d f r om

Tr a v e le d t o (include name and

Rou n d t r ip

Pa r k in g /

Tolls/

Fe ch a

(include address)

address of doctor, hospital, therapist,

m ile a g e /

Est a cion amiento

Pe a j e s

 

Viajó d e sd e

etc.)

Millas del viaje

 

 

 

(incluya dirección)

Viajó a (incluya nombre y dirección

entero

 

 

 

 

del médico, hospital, terapeuta, etc.)

 

 

 

Sample:

Sample: 1515 Maple,

Sample: Dr. Sherman, 190

Sample:

Sample:

Sample:

1/1/21

San Francisco

Oak, San Francisco

14 mi

$2.50

$

California law requires the following to

Total miles / Número de millas

 

x $.56 / mile =

 

$

 

 

appear on this form: Any person who

viajadas en total

 

 

 

 

knowingly presents a false or fraudulent

 

 

 

Total parking/Estacion-

 

$

 

 

 

amiento pagado en total

 

claim for the payment of a loss is guilty

 

 

 

 

 

 

 

 

 

 

 

 

 

Total tolls/Peajes

 

 

of a crime and may be subject to fines

 

 

 

 

$

 

 

 

pagados en total

 

and confinement in state prison.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tot a l r e im b u r se m e n t r e q u e st e d / Reembolso

 

$

 

 

 

solicitado en total

 

 

Las Leyes de California establecen que la

 

 

 

 

 

 

siguiente declaración aparezca en este

 

 

 

 

 

 

formulario: Cualquier persona que a

Sig n a t u r e /

Fir m a

 

 

 

 

sabiendas presente reclamos falsos o

 

 

 

 

 

 

fraudulentos para el pago de una pérdida,

 

 

 

 

 

 

es culpable de un delito y podría ser

Pr in t e d n a m e / I m p r im a su n om b r e

 

 

 

 

sujeto a multas y encarcelamiento en una

 

 

 

 

 

 

prisión estatal.

D a t e /

Fe ch a

 

 

 

 

I&A mileage form (for mileage after 01/01/2021)

Rev. 12/20

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