Workers Compensation Request for Reimbursement of Expenses - Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and workers’ compensation claim number at the top of the form. Ensure that all information is accurate to avoid delays.
3. Fill in your mailing address, including any apartment number or P.O. Box, and check the box if this is a new address.
4. In the Transportation section, provide details such as start and end locations, medical provider, trip miles, and date. Calculate total miles for reimbursement.
5. For Meals, list each meal's date and city along with costs for breakfast, lunch, and dinner. Sum these amounts for total meal reimbursement.
6. In the Lodging section, include hotel/motel name, location, date of stay, and cost. Total lodging reimbursement should be calculated here.
7. Document any prescriptions by entering medication name, doctor’s name, date of purchase, and cost. Calculate total prescription reimbursement.
8. Finally, sign and date the form to certify that all information provided is true before submitting it to your insurer.

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