I A Mileage Form PDF Details

It can be daunting to fill out a mileage form. It may not seem like the most interesting of tasks, or you may find yourself feeling overwhelmed and unsure of how to get started. The good news is that with the right information and some organization, it doesn't have to be complicated. In this post, we'll go through exactly what needs to be included on your mileage forms, as well as offer other tips for completing them accurately and in a timely manner!

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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For you to fill out this PDF document, be sure you provide the right details in every field:

1. First, while filling in the medical form mileage, start in the part that includes the next blanks:

Step no. 1 for submitting form mileage printable

2. Once your current task is complete, take the next step – fill out all of these fields - with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step # 2 in submitting form mileage printable

As to this field and next field, make sure you get them right here. These two could be the most important fields in this form.

3. The following segment is normally fairly uncomplicated, California law requires the, Total miles Número de millas, x mile, Total parkingEstacion amiento, Tot a l r e im bu r se m e n t r e, Sign a t u r e Firm a, Las Leyes de California establecen, Pr in t e d n a m e I m prim a su, and D a t e Fe ch a - each one of these fields must be filled out here.

Ways to complete form mileage printable step 3

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