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Fillable Printable Workers Compensation Mileage Reimbursement Form - New York

Fillable Printable Workers Compensation Mileage Reimbursement Form - New York

Workers Compensation Mileage Reimbursement Form - New York

Workers Compensation Mileage Reimbursement Form - New York

State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES
AND REQUEST FOR REIMBURSEMENT
WCB CASE NO. SOCIAL SECURITY NO.CLAIMANT'S NAME
In connection with the above workers compensation
case, you are entitled to be reimbursed for (1) drugs,
crutches or any apparatus properly prescribed by your
doctor and for (2) fares, automobile mileage or other
necessary expenses going to and from your doctor's
office or the hospital.
To help you keep a record of such expenses we have
provided this form. In order to help insure that you are
properly reimbursed, list each item of expense below--
whether or not you obtained a receipt (wherever
possible obtain receipts). Submit the completed form
and copies of all receipts or bills to the workers'
compensation insurance carrier (or to your
employer, if self-insured) and to the Workers'
Compensation Board. (See Board address on
reverse.) It is suggested that you retain a copy of the
receipts and bills for your records.
En relación con el caso de compensación para
trabajadores antes mencionado, usted tiene derecho a
recibir un reembolso por (1) medicamentos, muletas o
cualquier aparato indicado como corresponde por su
médico y (2) tarifas, millaje de automóvil u otros gastos
necesarios para trasladarse desde y hasta el consultorio
de su médico u hospital.
Le proporcionamos este formulario para ayudarlo a
llevar un registro de esos gastos. Con el objetivo de
garantizar que usted reciba el reembolso
correspondiente, enumere cada ítem de gasto a
continuación, tenga o no un recibo por ese gasto
(siempre que sea posible, intente obtener un recibo).
Envíe el formulario completo y copias de todos los
recibos o facturas a la compañía de seguros de
compensación para trabajadores (o a su empleador en
caso de que tenga un seguro propio) y a la Junta de
Compensación para Trabajadores (Workers'
Compensation BoardLe sugerimos que guarde una
copia de los recibos y facturas para sus registros.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
LA JUNTA DE COMPENSACIÓN OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR.
AMOUNT /
CANTIDAD
DATE /
FECHA
NATURE
OF
EXPENSE
/ TIPO
DE
GASTOS
C-257 (9-10)
Continue on Reverse. - Sigue al dorso.
RESIDENTIAL ADDRESS MAILING ADDRESS (IF DIFFERENT)
AMOUNT /
CANTIDAD
DATE /
FECHA
NATURE
OF
EXPENSE
/ TIPO
DE
GASTOS
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