Travel reimbursement request form 2026

1. Click ‘Get Form’ to open the travel reimbursement request form in the editor.
2. Begin by filling in your worker information. Include your name, date of injury, home address (not a PO Box), city, state, zip code, and phone number.
3. Select the reason for travel by checking only one type of travel per form: medical visit, vocational services, or attending a retraining class.
4. In the travel information section, indicate whether you have attached your expense receipts by selecting 'Yes' or 'No'.
5. Complete each column for your travel details: Date traveled, travel code (refer to the provided codes), cities traveled from and to, provider name and reason for visit, total miles traveled round trip, and expense cost.
6. Ensure that you obtain the required signatures from the provider or office staff for verification of each appointment date.
7. Finally, sign the form yourself to confirm that these expenses are related to your workers’ compensation claim and that you have not been reimbursed for them.

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