Saif Reimbursement Request Form PDF Details

Understanding the intricacies of the Saif Reimbursement Request form is essential for individuals seeking compensation for expenses incurred due to workplace injuries or conditions. This form, designed by the SAIF Corporation, requires detailed documentation including a claim number, with the purpose of facilitating the reimbursement process for various expenses. The form covers reimbursements for prescription medications, transportation, meals, and lodging, each with specific instructions. For medications, it specifies that the pharmacy slip must be submitted, not just a cash register receipt, ensuring that the details of the physician, medication, date filled, and amount paid are accurately recorded. Transportation claims necessitate details about the journey, including start and end locations, miles traveled, and the total cost, while meal and lodging reimbursements require information on the amounts spent, with the understanding that these are only covered if the claimant has to travel a significant distance for treatment. Notably, the form stipulates a two-year deadline from the date of service for submitting reimbursement requests. It includes a certification by the claimant that all information provided is truthful, under penalty of law, underscoring the legal obligations involved. Additionally, the form details the reimbursement rates for meals, lodging, and mileage, highlighting variations for specific locations within Oregon, which acknowledges the differing costs associated with different areas. This comprehensive document underscores SAIF Corporation’s commitment to supporting individuals in their recovery process, while also implementing measures to ensure the accuracy and integrity of claims.

QuestionAnswer
Form NameSaif Reimbursement Request Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesJan, Washington, 2011, saif reimbursement of expenses form

Form Preview Example

Request for Reimbursement of Expenses

Complete form, including claim number, and send to SAIF Corporation. Itemized receipts for each item must accompany this completed form. For prescription medication, please include the pharmacy slip with the name of the physician, medication, date filled, and amount paid, rather than the cash register receipt. Incomplete requests will be returned for additional information. Reimbursement must be requested within 2 (two) years from date of service.

400 High St. SE, Salem, OR 97312 1.800.285.8525

Name

Claim Number

Street address

 

 

 

Apt. #

 

 

 

 

 

 

 

 

This is a new address

City

State

Zip

 

Phone

 

 

 

 

 

 

 

 

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSPORTATION

 

 

 

 

 

 

Start Location

End Location

 

Doctor or Hospital

 

Trip Miles Date $ Amount

$

TOTAL Transportation

Reimbursement

MEALS

Date $ Breakfast

City

Date

$ Lunch

City

Date

$ Dinner

City

$

TOTAL Meals

Reimbursement

LODGING

Hotel/Motel Name

Location

Date

$ Cost

$

TOTAL Lodging

Reimbursement

PRESCRIPTIONS

Name of Medication

Doctor

Date

$ Cost

$

TOTAL Prescription

Reimbursement

As attested to by my signature and under penalty of law, I certify that all information I have given in this request for reimbursement is true and contains no false statements and/or misrepresentation.

$

GRAND TOTAL

Reimbursement

Signature of worker:

Date:

F3056 C+D, 4/17/12

 

 

Meals and lodging will be reimbursed if you are required to travel a distance for medical treatment that would prohibit you from returning to your local area within a reasonable time frame. An example would be travel in excess of 75 miles each way for meals or a required overnight stay for lodging and meals.

Standard rates for the continental United States:

Lodging and meal rates

ALL Private Vehicle Mileage effective

effective Oct. 1, 2011

April 17, 2012 = 55.5 cents per mile

 

 

 

 

 

Breakfast

$11.50

Previous mileage rates:

Lunch

$11.50

01/01/11 = 51.0 cents per mile

Dinner

$23.00

01/01/10 = 50.0 cents per mile

Lodging

$77.00

 

 

 

 

Room tax is reimbursable in addition to the lodging allowance.

Per day rates exceed the standard rate

in the following Oregon locations:

County/City

Effective

Max. lodging rate

Meal rate*

 

dates

 

 

Clackamas

All year

$88

$61

Clatsop

10/1 – 6/30

$96

$51

 

7/1 – 8/31

$131

$51

 

9/1 – 9/30

$96

$51

Deschutes

10/1 – 6/30

$89

$61

 

 

 

 

 

7/1 – 8/31

$114

$61

 

 

 

 

 

9/1 – 9/30

$89

$61

Jackson/Klamath

All year

$82

$56

Lane

All year

$97

$51

Lincoln

10/1 – 6/30

$84

$56

 

7/1 – 8/31

$105

$56

 

9/1 – 9/30

$84

$56

Multnomah

All year

$113

$66

Washington

All year

$93

$51

*For meals, the following percentages shall be used: breakfast 25%; lunch 25%; dinner 50%