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The document provides a Mileage Worksheet for FSAFEDS participants to claim reimbursement for mileage and parking expenses related to medical visits. It outlines the necessary information to be documented, including mileage rates for 2020 and 2021, submission requirements, and an example of how to log expenses. A signed Certification and Authorization statement is required for reimbursement.

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Click ‘Get Form’ to open the Mileage Worksheet in the editor.
Begin by entering the date of your travel in the 'Date' column. This helps track when you incurred the expenses.
In the 'Provider Name & Address' field, input the name and address of your medical provider for each visit.
Select the type of service provided from options like medical, dental, vision, or prescription in the corresponding section.
Record the number of miles traveled in the 'Number of Miles Traveled' column. Multiply this by the mileage rate (e.g., $0.16) to calculate total costs.
If applicable, enter any parking costs in the designated field to ensure all expenses are documented.
Finally, complete the Certification and Authorization section by signing and dating it to validate your request for reimbursement.

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