Request for Reimbursement of Expenses Complete this form, including your workers’ compensation claim number, and send it to the insurer that processes your claim. Include copies of receipts for all items except private vehicle mileage. Incomplete requests will be returned for additional information. Reimbursement must be requested within two years from date of service. Name Claim number Mailing address Apt. # ( City State P.O. Box City This is a new address ) - ZIP Phone State ZIP TRANSPORTATION Start location End location Doctor or hospital Trip miles Date TOTAL miles MEALS Date Breakfast City $ Date Lunch City $ Date Dinner City $ $ $ $ $ $ $ $ TOTAL meals reimbursement LODGING Hotel/motel name Location Date Cost $ $ $ $ TOTAL lodging reimbursement PRESCRIPTIONS Name of medication Doctor Date Cost $ $ $ $ $ TOTAL prescription reimbursement By my signature, I certify that all information I have given in this request for reimbursement is true and contains no false statements or misrepresentations. TOTAL miles $ Signature of worker 440-3921 (1/11/DCBS/WCD/WEB) Date TOTAL meals, lodging, and prescription reimbursement American LegalNet, Inc. www.FormsWorkFlow.com Standard rates for the continental United States: Lodging and meal rates effective Oct. 1, 2010 Breakfast $11.50 Lunch $11.50 Dinner $23.00 Lodging $77.00 ALL private vehicle mileage effective Jan. 1, 2011 51.0 cents per mile Previous mileage rates: 01/01/10 – 50.0 cents per mile 01/01/09 – 55.0 cents per mile 08/01/08 – 58.5 cents per mile 03/19/08 – 50.5 cents per mile Room tax is reimbursable in addition to the lodging allowance. Lodging and meal rates exceed the standard rate in the following Oregon locations: Max. lodging rate $87 $93 $130 Meal rate* $61 $51 $51 Jackson/Klamath 9/1 – 9/30 10/1 – 6/30 7/1 – 8/31 9/1 – 9/30 All year $93 $88 $110 $88 $80 $51 $61 $61 $61 $56 Lane All year $97 $51 Lincoln 10/1 – 6/30 7/1 – 8/31 9/1 – 9/30 $83 $104 $83 $56 $56 $56 Multnomah Washington All year All year $113 $90 $66 $51 County Clackamas Clatsop Deschutes Effective dates All year 10/1 – 6/30 7/1 – 8/31 *For meals, the following percentages must be used: breakfast -- 25%; lunch -- 25%; dinner -- 50% Rates obtained from Bulletin 112. See bulletin for more information. American LegalNet, Inc. www.FormsWorkFlow.com