Fillable Printable Travel Reimbursement Request Form
Fillable Printable Travel Reimbursement Request Form
Travel Reimbursement Request Form
Mail completed forms to:
Department of Labor and Industries
PO Box 44269
Olympia WA 98504-4269
Travel Reimbursement
Request
•
You must have prior authorization from your claim manager. See WAC 296-20-1103 .
•
Read the instructions on the back before you start.
•
Traveling for an Independent Medical Examination? Find the IME travel form (F245-224-000) online at
Worker Information (please print)
Claim No.
Name (Last, First, Middle Initial)
Date of Injury
Home Address (not PO Box)
Social Security No. (For ID only)
City
State
Zip Code
Phone No.
Reason for Travel (check only one type of travel per form)
Medical visit or treatment Vocational services Attending retraining class (attach copy of
Transportation Encumbrance form [F245-375-000]
signed by your Vocational Counselor)
Travel Information – instruction and example on back
Did you attach your expense receipts? Yes No
A.
Date
(each trip)
mm/dd/yyyy
B.
Travel code
(one per line –
see back of form)
C.
From
(City)
D.
To
(city)
E.
Provider name & reason for
visit
F.
No. of miles
(round trip)
G.
Expense cost
(attach
receipts)
1.
2.
3.
4.
5.
6.
7.
Required: Signature of the provider or office staff to verify your appointment.
1.
Date
5.
Date
2.
Date
6.
Date
3.
Date
7.
Date
4.
Date
Required: Worker’s Signature
These expenses are related to my workers’ compensation claim and I have not been reimbursed for them. I
understand it is a crime to submit information I know is false. I have read and understand the instructions on
the back of this form.
Print Worker’s Name
Worker’s Signature
Date
F245-145-000 Travel Reimbursement Request 08-2014
www.Lni.wa.gov and click on Get a Form or Publication.
After the first visit for your claim, travel is only payable if you:
•
Have authorization from your claim manager and
•
See a provider who’s in the L&I Provider Network (exceptions may apply see link below).
Instructions: Complete each column.
•
Column A: Date you traveled (one date per line).
•
Column B: Use only one code per line. Codes are listed below.
•
Column C: City you traveled from.
•
Column D: City you traveled to.
•
Column E: Provider you saw and the reason for traveling.
•
Column F: Total number of miles you traveled round trip.
•
Column G: Dollar amount of each expense (food, lodging, fares, parking). Only one expense per line.
You must attach copies of all receipts except for parking under $10. All receipts must be itemized and
legible. Credit card receipts aren’t acceptable.
Travel Codes
Expense Medical Services Vocational Services Retraining
Private vehicle mileage 0401A V0028 0301R
Parking 0402A 0402A 0302R
Bridge & Ferry Toll 0403A 0403A 0303R
Commercial Transportation 0405A 0405A 0304R
Taxi 0414A 0414A Contact your Voc Counselor
Lodging 0406A 0406A Contact your Voc Counselor
Breakfast 0407A 0407A Contact your Voc Counselor
Lunch 0408A 0408A Contact your Voc Counselor
Dinner 0409A 0409A Contact your Voc Counselor
Signatures
•
Medical Visits: The provider or office staff you saw must sign to verify each visit date.
•
Vocational and Retraining Services: Your vocational counselor must sign to verify each date you
traveled.
•
Worker’s Signature: You need to sign the form for reimbursement.
Example
A.
Date
(each trip)
mm/dd/yyyy
B.
Travel code
(one per line –
see back of
form)
C.
From
(City)
D.
To
(city)
E.
Provider name & reason for
visit
F.
No. of miles
(round trip)
G.
Expense cost
(attach
receipts)
1.
08/08/2014
0401A
Olympia
Seattle
Dr. Smith; post-op visit
120
2.
08/08/2014
0402A
$25.00
Need to find a nearby L&I Network Provider?
Go to Find-A-Doc at www.FindADoc.Lni.wa.gov .
Need more help or information?
Go to www.Lni.wa.gov and click on the Injured Workers tab or call 1-800-LISTENS.
You can read the complete Travel Expense WAC by visiting apps.Leg.wa.gov/WAC/ and searching for WAC
296-20-1103.
F245-145-000 Travel Reimbursement Request 08-2014
