APPLICATION FOR REIMBURSEMENT OF CLAIM RELATED TRAVEL EXPENSES (Pursuant to NAC 616C.150) Please type or print and provide all the information requested. Keep and be prepared to provide, if requested, any receipts relating to your reimbursement request. Name (Last, First, Middle Initial) Claim Number Present Address (P.O. Box, Apt. No., Street) Social Security Number City State Zip Date of Injury Residence at time of injury: (For Insurers Use Only ) [__] Approved _______________ [__] Disapproved Initials & Date REPORT TRAVEL WEEKLY. See reverse side of this form for the regulations under which you may be reimbursed for claim related travel. Be aware that any misrepresentation may be considered fraud and is in violation of Nevada law. Daily Expense Reimbursement Mileage Beginning Point Enter Travel Leave Allowed of Travel Destination Time Travel Meals Miles One (For Insurers Use Date Address Name/Address Time Lodging Way Only) B L D TOTAL MILES: Total of Miles X 2 @ $ . per Mile = I hereby certify that the record provided above is correct to the best of my knowledge and that all of the mileage for which I am requesting reimbursement is related to or is for treatment authorized under Nevada Revised Statute (NRS) 616A to 616D, inclusive or chapter 617 of NRS. I understand that the reporting of false information may disqualify me from receiving workers compensation benefits, and may subject me to criminal and civil penalties. I certify under penalty of perjury that the above information is correct to the best of my knowledge. __________________________________________________ _________________________________ Injured Employees Signature Date D-26(1) (Rev.4/04) >>>> 2 Reimbursement for Costs of Transportation and Meals Nevada Administrative Code (NAC) 616C.150 Eligibility and computation. 1. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for the cost of transportation if he is required to travel 20 miles or more, one way, from: (a) His residence to the place where he receives medical care; or (b) His place of employment to the place where he receives mdical care if the care is required during his norme al working hours. 2. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for the cost of transportation if he is required to travel 20 miles or m, one way, fromore his residence or place of employment to a place of hearing designated by the insurer or the department of administration if the hearing concerns an appeal by the employer or insurer from a decision in favor of the injured employee and the decision is upheld on appeal. 3. An injured employee who does not qualify for reimbursement under paragraph (a) or (b) of subsection 1 but is required to travel a total of 40 miles or more in any one week for medical care or for attendance at the systems rehabilitation center is entitled to be reimbursed for the cost of his transportation. 4. Except as otherwise provided in subsection 6, reimbursemer the cost of transportation mnt fo ust be computed at a rate equal to: (a) The mileage allowance for state employees who use their personal vehicles for the convenience of the state; or (b) The expense actually incurred by the injured employee for transportation, if the injured employee consents to reimbursemt at enthis rate and the expense is not greater than the amount to which the injured employee would otherwise be entitled pursuant to paragraph (a). 5. Except as otherwise provided in subsection 6, if an injured employee must travel before 7:00 a.m. or between 11:30 a.mnd . a1:30 p.m. or cannot return to his home or place of employment until after 7:00 p.m., or any combination thereof, reimbursemfor ment eals required to be purchased must be computed at a rate equal to: (a) That allowed for state employees; or (b) The expense actually incurred by the injured employee for ms, if the injured emeal ployee consents to reimbursement at this rate and the expense is not greater than the amount to which the injured employee would otherwise be entitled pursuant to paragraph (a). 6. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for his expenses of travel if he is required to travel 50 miles or mre, one way, fromo his residence or place of employment and is required to remain away from his residence or place of employment overnight. Reimbursement must be computed at a rate equal to: (a) The per diem allowance authorized for state employees; or (b) The expenses actually incurred by the injured employee, whichever is less. 7. A claim for reimbursement of expenses governed by this section may be disallowed unless it is submitted to the insurer or employer within 60 days after the expenses are incurred. NAC 616C.153 Reimbursement for air fare. With the prior approval of the insurer or those employers who have elected to provide accident benefits, an injured employee may be reimbursed for air fare where the time, distance, convenience or cost justifies his travel by air. NAC 616C.156 Limitations on reimbursements. 1. Unless otherwise directed or approved by the insurer, or the injured employees treating physician or chiropractor, an injured employee who chooses to obtain his medical services at a mdistant place although adequate more edical care is available at a closer place may be reimbursed under NAC 616C.150 only for mileage to the closer place. 2. If a person moves outside this state or to a new location within this state for his own convenience after becoming an injured employee, the maximum mileage for one direction for which he mbe reimay bursed is the mileage allowable before the move or 40 miles, whichever is greater. 3. No reimbursement will be allowed for a person traveling with an injured employee unless there is a medical necessity that precludes the injured employee from traveling alone. The medical necessity must be substantiated in writing by the injured emoyeepls treating physician or chiropractor. Notice An injured employee or any other person who knowingly makes a false statement or representation or knowingly conceals a mal teria fact in order to obtain or attempt to obtain any benefit m subject to both civil penalties and crimay be inal prosecution. If convicted, a person forfeits all rights to workers compensation benefits and is liable for reasonable in