REIMBURSEMENT FOR HEALTH CARE TRAVEL EXPENSES PURSUANT TO SECTION 72-432(1), IDAHO CODE Name of Injured Worker _______________________________ Carrier Claim # ____________________ SSN ___________________Address ______________________________________________________ Phone # ______________________ Date of Injury/Manifestation____________________________ Date // // // // // Less 15 Miles for Each Round Trip Total Allowable Miles* Current Mileage Rate** $ Total Reimbursement Request $ /mile Medical Provider Provider Address and City Round Trip Miles 1. Use this form when claiming reimbursement for travel expenses incurred while pursuing reasonable or necessitated diagnosis, treatment, or care of an industrial injury or occupational disease. 2. *Only mileage in excess of fifteen (15) miles for any given round trip is reimbursable. However, you should report the total mileage for each round trip. You are expected to take the shortest practical route of travel. 3. **Reimbursement shall be made at the mileage rate allowed by the State Board of Examiners for state employees. The current rate for this mileage is available through your insurance company, by contacting the Idaho Industrial Commission, or by visiting http://www.sco.idaho.gov. 4. While prompt submittal of your claim for travel reimbursement is important, you should not submit requests for reimbursement more frequently than once every thirty (30) days. 5. YOU MUST ATTACH TO THIS FORM A COPY OF A BILL OR RECEIPT SHOWING THAT EACH VISIT OCCURRED IC FORM 432(1) American LegalNet, Inc. www.FormsWorkFlow.com