Free - Arkansas

Medical Mileage Please list the miles round trip from your home and back. Leave the total blank. Keep one copy for your records. DATE NAME OF DOCTOR, PHYSICAL THERAPIST HOSPITAL, DRUG STORE, ETC. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ MILES ROUND TRIP ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ TOTAL___________ Please print your name: ______________________________________ Claim #_____________ Address:____________________________ Telephone # ___________________ Employer: _________________________ Today's Date ___________________ Please send one copy to your employer or the insurance carrier. Do not send this worksheet to the Commission.

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