· Listtraveldatesinchronologicalorder. Example Help prevent delays in reimbursement Correct month/day/year Completing the Injured Worker Statement for Reimbursement of Travel Expense 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. 1. DATE 2. Incorrect month/day/year DATE Jan.4,2014 Jan.17,2014 Jan.31,2014 Jan.31,2014 Jan.4,2014 March17,2014 · Submitthisformimmediatelyafteryourtriporassoon asyouhavefilledthetravellines. 1. 2. 3. 4. Injured worker information-Complete. Dateof travel-Entermonth,dayandtheyearthat youtraveledtoreceiveservice. Travel -Indicatethecitiesyoutraveledfromandto. Useonlyonefromandtoboxperroundtrip. Total car mileage per trip -Entertheamountof milestraveledtoyourdestinationeachday.The distancemustbegreaterthan45milesroundtrip perday.BWCmustauthorizemileageinexcessof 400milesroundtripinadvance. b. In-state meals:Entertheactualamount. Youmusttravelaminimum of100milesone waytoreceivereimbursementformeals. Reimbursementappliestoinjuredworkeronly. BWCwillreimbursecompanionexpensesonly ifitauthorizedcompaniontravelinadvance. Out-of-state meals:BWCwillreimbursefor mealsperday,nottoexceedthecurrent maximumrate.Reimbursementappliesto theinjuredworkeronly.BWCwillreimburse companionexpensesonlyifitauthorized companiontravelinadvance. NOTE: Whenrequestedtoappearforamedical examinationbyaphysicianoftheemployer's choice,thereisnominimummileagerestriction forcarmileagereimbursement.Submitthetravel expensestatementformtotheemployer. 5. Other types of travel/Out-of-state travel-This includestravelbybus,taxi,train,airorother specialtransportationthatisgreaterthan45miles roundtrip.BWCmustauthorizesuchtravelin advance.Reimbursementappliestoinjuredworker only.BWCwillreimbursecompanionexpensesonly ifitauthorizedcompaniontravelinadvance.BWC requiresreceiptsandreimbursesforactualfare. a. Type: Enterthetypeoftransportationused. b. Cost:Enterthecostoftransportationused. Other expenses-Includesmiscellaneous,meals, andlodging. a. Miscellaneous: Enterexpensesforparkingand tollsonly.BWCrequiresreceiptsandwillpay reimbursementfortheactualamount. NOTE: c. In-state lodging:Entertheactualamount.BWC mustauthorizelodginginadvance.BWCwill payreimbursementnottoexceedthecurrent maximumrateonthedateoftravel. Receipts willberequired. Out-of-state lodging:BWCwillreimbursefora commercialestablishmentatreasonableactual cost. 7. 6. Reason for travel ­Pleaseindicatethereason youarerequestingtravelreimbursementby checkingoneoftheoptions.IfyoucheckEmployer scheduledexam,pleasesubmitthisrequestformto youremployerforreimbursement. Signature and date-Signyourfullnameandthe dateyoucompletedthisform. 8. If you are an injured worker employed by a self-insuring employer, complete this form and return it to your employer. American LegalNet, Inc. www.FormsWorkFlow.com Injured Worker Statement for Reimbursement of Travel Expense Prevent delays in reimbursement · Listtraveldatesintheorderyoutooktrips. · Submitthisformimmediatelyafteryourtriporas soonasyoucompletethetravellines. · Typeorprintlines1-7,signline8. 1. Last name Street address or P.O. box City 2. Date month/day/year From To From To From To From To From To 7. 8. Check reason for travel: BWC scheduled exam Employer scheduled exam Managed care organization scheduled exam Industrial Commission of Ohio (IC) scheduled exam Pre-authorized specialized treatment Vocational Rehabilitation 3. Travel State 4. 3 Total car mileage per trip Nine-digit ZIP code 5. a. First Return completed form to: M.I. Claim number Social Security number Telephone number ( 6. a. Misc. ) Other expenses b. Meals c. Lodging Other types of travel b. Costs Type 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. Signature: Date: I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC, or who knowingly accepts payment to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Official use only Check only if charged to Surplus Fund BWC W0501 - Travel & Misc. W0502 - Meals W0503 - Lodging $ $ $ Sub total Total meals 6b. Total lodging 6c. Total amount to be reimbursed Official approval signature $ $ $ $ Date Telephone number ( ) User name (A number) Procedure codes IC W0515 - Travel and Misc. W0516 - Meals W0517 - Lodging Amount (rate per mile) Code Rehabilitation W0600 - Travel and Misc. W0601 - Meals W0602 - Lodging TCN Mileage, meals and lodging calculations Total car mileage 4. Total other types of travel 5b. Total miscellaneous 6a. X BWC-1178 (Rev. Nov. 17, 2014) Distribution: BWC claim file, injured worker American LegalNet, Inc. www.FormsWorkFlow.com s s C-60