E3065 2026

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141 votes

The document is a Medical Mileage Expense Form for individuals entitled to reimbursement of travel expenses related to medical visits due to industrial injuries. It provides instructions on how to complete the form, details about mileage rates based on travel dates, and legal warnings against fraudulent claims. The form must be sent to designated State Fund Claims Processing Centers along with receipts for expenses incurred.

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Click ‘Get Form’ to open the e3065 in the editor.
Begin by entering the Injured's Name and Claim Number at the top of the form. Ensure that these details are accurate as they are crucial for processing your reimbursement.
In the Medical Mileage Expense section, list each trip you made for medical purposes. Include the date, starting address, destination (doctor or hospital), and round trip mileage.
Refer to the mileage rates provided for the specific dates of travel. Calculate your total reimbursement by multiplying the miles traveled by the applicable rate.
Don’t forget to include any additional expenses such as parking fees or tolls. Attach receipts for these costs to ensure full reimbursement.
Finally, sign and print your name at the bottom of the form, then save a copy for your records before submitting it to your claims adjuster.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (195 Votes)
2017	4.4 Satisfied (45 Votes)
2015	4.3 Satisfied (141 Votes)
2013	4.2 Satisfied (35 Votes)

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