Mileage Reimbursement Form PDF Details

Navigating the path to obtaining mileage reimbursement for travel to medical facilities as part of a workers’ compensation case can often seem daunting. At its core, the Mileage Reimbursement Form plays a crucial role in this journey, serving as the requisite document to claim travel expenses. This form requires claimants to furnish vital details including their name, social security number, address, the date of the accident, travel dates, and the name of the medical facility visited, excluding pharmacies. Claimants are also required to provide the round-trip mileage from their residence to the facility, thereby affirming that these travels were necessary for medical appointments related to their workers’ compensation case. It is imperative for individuals to certify the accuracy of this information, as the form also contains stern warnings against the submission of false or misleading information, outlining possible repercussions under Florida Statute 440.105(7). A personal signature from the claimant further attests to their understanding and acknowledgment of these terms, with a clear stipulation that any refusal to sign equates to a suspension of benefits or payments until compliance is achieved. The elements of this form underscore the importance of transparency and accuracy in the pursuit of rightful reimbursement, serving as a safeguard for both the individual and the system at large against fraudulent claims.

QuestionAnswer
Form NameMileage Reimbursement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedical mile florida worker comp forms, mtm florida mileage reimbursement form, forida workers compensation mileage reimbursement form, workers compensation request for mileage reimbursement

How to Fill Out Mileage Reimbursement Form

Mileage Reimbursement Form at a glance

What it is: Mileage reimbursement form for the round-trip mileage to and from residence and the name of the medical facility.

A filled-in Mileage Reimbursement Form example: a claimant lists two medical visits

Mileage Reimbursement Form example filled out, example: a claimant lists two medical visits
Maria Sample files the Mileage Reimbursement Form after a workplace injury. She lists two visits to Sample Clinic, 14 and 22 round-trip miles from her home. Only two rows are used, so the date of travel rows below stay empty; all its values are invented.

How to fill out Mileage Reimbursement Form, box by box

Claimant name, social security number, address and date of accident

Mileage Reimbursement Form example filled out, claimant name, social security number, address and date of accident

Write the claimant name on the Mileage Reimbursement Form.

Enter the social security number.

Enter the claimant address.

Enter the date of accident.

Date of travel, name of medical facility and round-trip mileage

Mileage Reimbursement Form example filled out, date of travel, name of medical facility and round-trip mileage

Enter the date of travel.

Enter the name of the medical facility, excluding pharmacies.

Enter the round-trip mileage to and from residence.

Claimant's Signature and Today's Date

Mileage Reimbursement Form example filled out, claimant's Signature and Today's Date

You certify and affirm that the mileage in ROUND-TRIP MILEAGE TO & FROM RESIDENCE was incurred by you as necessary traveling expenses related to those medical facility visits pursuant to your workers' compensation case. An injured employee or any other party making a claim under Florida Statute 440.105(7) shall provide his or her personal signature attesting that he or she has reviewed, understands, and acknowledges the following statement: “Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234.” If the injured employee or other party refuses to sign the document attesting that he or she has reviewed, understands, and acknowledges the statement, benefits, or payments under this chapter shall be suspended until such signature is obtained. Sign at Claimant's Signature.

Enter Today's Date.

Sources

[1] Mileage Reimbursement Form, Florida workers' compensation (no issuer file found) (the Official source link on this page).

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