Travel Reimbursement Request {F245-145-000}

Mail completed forms to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269 · · · Travel Reimbursement Request You must have prior authorization from your claim manager. See WAC 296-20-1103. Read the instructions on the back before you start. Traveling for an Independent Medical Examination? Find the IME travel form (F245-224-000) online at www.Lni.wa.gov and click on Get a Form or Publication. Claim No. Date of Injury Social Security No. (For ID only) State Zip Code Phone No. Worker Information (please print) Name (Last, First, Middle Initial) Home Address (not PO Box) City Reason for Travel (check only one type of travel per form) Medical visit or treatment Vocational services Attending retraining class (attach copy of Transportation Encumbrance form [F245-375-000] signed by your Vocational Counselor) Travel Information ­ instruction and example on back Did you attach your expense receipts? A. Yes D. No F. Date B. (each trip) mm/dd/yyyy 1. 2. 3. 4. 5. 6. 7. Travel code C. (one per line ­ see back of form) From (City) To E. (city) Provider name & reason for visit No. of miles (round trip) G. Expense cost (attach receipts) Required: Signature of the provider or office staff to verify your appointment. 1. 2. 3. 4. Date Date Date Date 5. 6. 7. Date Date Date Required: Worker's Signature These expenses are related to my workers' 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. Print Worker's Name Worker's Signature Date F245-145-000 Travel Reimbursement Request 08-2014 American LegalNet, Inc. www.FormsWorkFlow.com After the first visit for your claim, travel is only payable if you: · Have authorization from your claim manager and · See a provider who's in the L&I Provider Network (exceptions may apply see link below). Instructions: Complete each column. · · · · · · · Column A: Date you traveled (one date per line). Column B: Use only one code per line. Codes are listed below. Column C: City you traveled from. Column D: City you traveled to. Column E: Provider you saw and the reason for traveling. Column F: Total number of miles you traveled round trip. Column G: Dollar amount of each expense (food, lodging, fares, parking). Only one expense per line. You must attach copies of all receipts except for parking under $10. All receipts must be itemized and legible. Credit card receipts aren't acceptable. Travel Codes Expense Private vehicle mileage Parking Bridge & Ferry Toll Commercial Transportation Taxi Lodging Breakfast Lunch Dinner Medical Services 0401A 0402A 0403A 0405A 0414A 0406A 0407A 0408A 0409A Vocational Services V0028 0402A 0403A 0405A 0414A 0406A 0407A 0408A 0409A Retraining 0301R 0302R 0303R 0304R Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Contact your Voc Counselor Signatures · · · Medical Visits: The provider or office staff 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: You need to sign the form for reimbursement. Example A. Date B. (each trip) mm/dd/yyyy 1. 2. Travel code C. (one per line ­ see back of form) From (City) D. To E. (city) Provider name & reason for visit F. No. of miles (round trip) G. Expense cost (attach receipts) 08/08/2014 08/08/2014 0401A 0402A Olympia Seattle Dr. Smith; post-op visit 120 $25.00 Need to find a nearby L&I Network Provider? Go to Find-A-Doc at www.FindADoc.Lni.wa.gov. Need more help or information? Go to www.Lni.wa.gov and click on the Injured Workers tab or call 1-800-LISTENS. You can read the complete Travel Expense WAC by visiting apps.Leg.wa.gov/WAC/ and searching for WAC 296-20-1103. F245-145-000 Travel Reimbursement Request 08-2014 American LegalNet, Inc. www.FormsWorkFlow.com