Mileage Worksheet For Medical Treatment | Pdf Fpdf Doc Docx | Connecticut

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Mileage Worksheet For Medical Treatment | Pdf Fpdf Doc Docx | Connecticut

Last updated: 12/1/2006

Mileage Worksheet For Medical Treatment

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Description

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 = American LegalNet, Inc. www.FormsWorkflow.com / / / / / / Rev. 3-17-2006

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