Free F245-145-000 travel reimbursement request - English - Washington

Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269

TRAVEL REIMBURSEMENT REQUEST

Claim No.

Injured Worker Information
Worker's name
(Last, First, Middle Initial)

Date of injury Apt # State ZIP Social Security No. (for ID only) Worker's Phone Number

Worker's home address (not PO Box) City

Travel Information Why did you travel? If you check more than 1 box, you must use a separate form for each type of travel.
I traveled for a medical visit or to receive treatment I traveled to receive vocational services I traveled to receive retraining (Attach copy of Transporation Encumbrance form)

Read the instructions on the back of this form before you complete this section.
One travel or From: (Each Trip expense code (city where you or expense) (mm dd yyyy) per line (from lived on travel back of form) date)

A Date

B

C

D

E
To: (City)

F
Round Trip Mileage

G

Provider seen and reason for visit

Mileage Cost (optional see back)

H
Expense costs as listed on back (one per line)

1. 2. 3. 4. 5. 6. 7. Totals

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

Signature Requirements:
Signature of the person you traveled to see: 1) Medical Visits - the person you saw must sign to verify each date you traveled. 2) Vocational and Retraining services - your vocational counselor must sign to verify each date you traveled.
Date and authorizing signature of person visited Date and authorizing signature of person visited Date and authorizing signature of person visited

1. Date 2. Date 3. Date

4. Date 5. Date 6. Date

7. Date

Worker's Signature (forms not signed will be returned)
Date Worker's signature

RESET

These expenses are related to my worker's compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I have read and understand the instructions on the back of this form.

F245-145-000 travel reimbursement request 7-08

Read these instructions carefully before you complete this form. We can only reimburse you if your form is complete, correct, and signed. Important information
If you traveled for an Independent Medical Exam (IME), this is not the correct travel form. Please find IME travel form F245-224000 on the L&I Web site ( http://www.LNI.wa.gov/IPUB/245-224-000.pdf ) or call Provider Hotline 1-800-848-0811. Per RCW 51.36.020, Reasonable travel expenses for orthotic/prosthetic repairs or replacement are payable (except for hearing aids) after your claim is closed if both of these conditions apply: 1) The appliance was originally purchased by L&I or your self-insured employer; and 2) You travel on or after 6/12/08 NOTE: Other travel expenses are not payable when your claim is closed or you are on pension, unless requested by L&I or your self-insured employer. For medical and treatment visits, travel expense is only payable when you must travel more than 10 miles each way (over 20 miles round trip) to the nearest point of adequate treatment*. Travel expense is not payable beyond the nearest point of adequate treatment, even if you prefer to seek treatment at another location. · *The 10 mile rule is waived if L&I or your self-insured employer requested the exam, and for vocational appointments. · Travel expenses are not payable for driving to the pharmacy to get prescriptions filled. · You can search for L&I providers near you with Find-A-Doc: www.LNI.wa.gov/ClaimsIns/Claims/FindaDoc/ Per the travel WAC 296-20-1103: · L&I must receive your travel voucher within 12 months from the date of travel to be considered for payment. · Without approval from your claim manager in advance, you may not be reimbursed for travel expenses.

Completing the form
Injured Worker Information: Complete as indicated. Be sure to write your home address, not PO Box. Travel Information: Check the box for the type of travel. Use a separate form for each type of travel.

Columns:
A - Date of trip or expense. Write only one date per line. B - Codes on chart below are listed by travel type, for example if charging to drive your car to a doctor visit, write code 0401A. Medical Services Vocational Services Private vehicle mileage 0401A V0028 Parking** 0402A 0402A Bridge & Ferry toll* 0403A 0403A Commercial Transportation* 0405A 0405A Taxi* 0414A 0414A Lodging* 0406A 0406A Breakfast* 0407A 0407A Lunch* 0408A 0408A Dinner* 0409A 0409A *Copy of receipt required, other restrictions may apply. ** Parking receipt required if $10 or more

Codes: If you traveled for

Retraining 0301R 0302R 0303R 0304R Contact Voc Counselor Contact Voc Counselor Contact Voc Counselor Contact Voc Counselor Contact Voc Counselor

C - This must be the city where you lived on the date you traveled. D - Name of the city you visited. E - Write the name of the person you saw, and the reason for your visit (such as exam, PT, or vocational). F - List the total number of miles you traveled round trip. G - OPTIONAL1 - List the total mileage charge by multiplying round trip miles times the department rate on the date of travel. Mileage rate can be found on the GSA website (www.gsa.gov/mileage), or call Provider Hotline 1-800-848-0811. 1 Department will calculate cost. H - Write in the dollar amount of each expense on a separate line (food, lodging, fares, parking). You must attach all receipts. It is recommended to send copies and keep the original receipts.

Signature requirements:
Medical Visits - The person you saw must sign to verify each visit date. Vocational and Retraining services - Your Vocational Counselor must sign to verify each date you traveled. Worker's signature - Travel will not be reimbursed unless form has the worker's signature.

F245-145-000 backer 7-08