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Rev 01 2017 d14 866-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Social Security Number and your name in the designated fields. This information is crucial for processing your reimbursement claim.
- Fill in your employer's name and the date of the accident, ensuring accuracy to avoid any delays.
- In the section labeled 'NAME AND ADDRESS OF PHYSICIAN OR MEDICAL FACILITY', provide the necessary details of your healthcare provider.
- For each day you are claiming mileage reimbursement, enter the date(s) in the specified field, along with your starting address and final destination after your doctor's appointment.
- Calculate and input the round trip miles traveled in the corresponding field. Ensure this is accurate as it affects your reimbursement amount.
- Finally, sign and date the form at the bottom before submitting it to ensure that all information is verified and complete.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 1999 | 4 Satisfied (59 Votes) |
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