Free FORM - Connecticut

Mileage Worksheet for Medical Treatment -- Examination -- Physical Therapy -- Laboratory Test
[Section 31-312 C.G.S.]

Employee Name
(Please TYPE or PRINT IN INK)

Date of Injury

Claim #

Employer Name







DATE:
Month / Day / Year

FROM:
City / Town , State

TO:
City / Town , State

REASON FOR VISIT -- NAME OF PHYSICIAN
or Other Health Care Provider



ROUND-TRIP MILEAGE:

















































































































































/

/

















































/

/































DATE SUBMITTED

TOTAL MILEAGE =







































/

/





















/

/





















/

/





















Rev. 3-17-2006