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Injured Worker Reimbursement Rates For Travel Expense Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Injured Worker Reimbursement Rates For Travel Expense, BWC-1186, Ohio Workers Comp, Injured Workers
Completing the
Help prevent delays in reimbursement
• List travel dates in chronological order.
Example
Correct
1.
DATE
Injured Worker Statement for
Incorrect
2.
Reimbursement of Travel Expense
DATE
month/day/year
month/day/year
1/4/2008
1/17/2008
1/31/2008
1/31/2008
1/4/2008
3/17/2008
BWC pays reimbursements in 4 and 6 based on the rate
effective at the time of travel. Rates are subject to change
every year. If you have any questions regarding the rates,
please contact the customer service office listed on the
front of the form.
• Submit this form immediately after your trip or as
soon as you have filled the travel lines.
1. Injured worker information - Complete.
reimbursement for the actual amount.
2. Date of travel - Enter month, day and the year
that you traveled to receive service.
3. Travel - Indicate the cities you traveled from and
to. Use only one from and to box per round trip.
4. Total car mileage per trip - Enter the amount of
miles traveled to your destination each day. The
distance must be greater than 45 miles round trip
per day. BWC must authorize mileage in excess of
400 miles round trip in advance.
NOTE: When you have been requested to appear for
a medical examination by a physician of the
employer's choice, there is no minimum mileage
restriction for car mileage reimbursement.
Submit the travel expense statement form to the
employer.
5. Other types of travel/Out-of-state travel - This
includes travel by bus, taxi, train, air or other
special transportation that is greater than 45 miles
round trip. BWC must authorize such travel in
advance. Reimbursement applies to injured worker
only. BWC will reimburse companion expenses only
if it authorized companion travel in advance. BWC
requires receipts and reimburses for actual fare.
a. Type: Enter the type of transportation used.
b. Cost: Enter the cost of transportation used.
6. Other expenses - Includes miscellaneous, meals,
and lodging.
b. In-state meals: Enter the actual amount.
You must travel a minimum of 100 miles one
way to receive reimbursement for meals.
Reimbursement applies to injured worker only.
BWC will reimburse companion expenses only
if it authorized companion travel in advance.
Out-of-state meals: BWC will reimburse for
meals per day, not to exceed the current
maximum rate. Reimbursement applies to
the injured worker only. BWC will reimburse
companion expenses only if it authorized
companion travel in advance.
c. In-state lodging: Enter the actual amount.
BWC must authorize lodging in advance. BWC
will pay reimbursement not to exceed the
current maximum rate on the date of travel.
Receipts will be required.
Out-of-state lodging: BWC will reimburse
for a commercial establishment at reasonable
actual cost.
7. Reason for travel – Please indicate the reason you
are requesting travel reimbursement by checking
one of the options. If you check Employer
scheduled exam, please submit this request form
to your employer for reimbursement.
8. Signature and date - Sign your full name and the
date you completed this form.
a. Miscellaneous: Enter expenses for parking and
tolls only. BWC requires receipts and will pay
NOTE:
If you are an injured worker employed by a self-insuring
employer, complete this form and return it to your
employer.
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Injured Worker Statement for
Reimbursement of Travel Expense
Return completed form to:
Prevent delays in reimbursement
• List travel dates in the order you took trips.
• Submit this form immediately after your trip, or
as soon as you complete the travel lines.
• Type or print lines 1-7, sign line 8.
M.I.
First
1. Last name
Social Security number
Street address or P.O. box
City
State
2.
Claim number
4.
3 Total
car mileage
per trip
3.
Travel
Date
month/day/year
Nine-digit ZIP code
5.
Other types of travel
b. Costs
Type
a.
Telephone number
( )
6.
Other expenses
a. Misc.
b. Meals
c. Lodging
From
To
From
To
From
To
From
To
From
To
7. Check reason for travel:
BWC scheduled exam
IC scheduled exam
MCO scheduled exam
Employer scheduled exam
Pre-authorized specialized treatment
Vocational Rehabilitation
I, the injured worker, certify the statements made on this travel expense statement are true, and that all expenditures were used for the travel expenses indicated.
8.
Signature:
Date:
Official use only
Procedure codes
Check only
if charged to
Surplus Fund
Industrial Commission of Ohio
W0515 - Travel & Misc.
W0516 - Meals
W0517 - Lodging
BWC
W0501 - Travel & Misc.
W0502 - Meals
W0503 - Lodging
Mileage, meals and lodging calculations
X
Total car mileage 4.
Amount
(rate per mile)
Code
Rehabilitation
W0600 - Travel & Misc.
W0601 - Meals
W0602 - Lodging
TCN
$
$
Total other types of travel 5b.
$
Total miscellaneous 6a.
s
Sub total
$
Total meals 6b.
$
Total lodging 6c.
$
Official approval signature
BWC-1178 (Rev. 2/26/2008)
C-60
s
Total amount to be reimbursed
$
Date
Telephone number
( )
User name (A#)
Distribution: BWC claim file, injured worker
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www.FormsWorkflow.com
