Free TRAVEL~1.PDF - Idaho

REIMBURSEMENT FOR HEALTH CARE TRAVEL EXPENSES
PURSUANT TO IDAHO CODE §72-432(1)

Name of Injured Worker Claim # Address

____________________________________
SSN:

______________________

____________________

________________________________________________ ________________________________________________

Phone #

______________________

______________________________ Claimant's Signature

______________ Date Signed

________________________ Date Received by Surety

1. Use this form when claiming reimbursement for travel expenses incurred while pursuing reasonable or necessitated diagnosis, treatment, or care of an industrial injury or occupational disease. 2. Only mileage in excess of fifteen (15) miles for any given round trip is reimburseable. However, you should report the total mileage for each round trip. You are expected to take the shortest practical route of travel. 3. Reimbursement shall be made at the mileage rate allowed by the State Board of Examiners for state employees. The current rate for this mileage is available through your insurance company or by contacting the Idaho Industrial Commission. 4. While prompt submittal of your claim for travel reimbursement is important, you should not submit requests for reimbursement more frequently than once every 30 days.

YOU MUST ATTACH TO THIS FORM A COPY OF A BILL OR RECEIPT SHOWING THAT EACH VISIT OCCURRED.
5.

IC Form 432(1)

IDAPA 17.02.04.321