Request for Reimbursement of Expenses Complete this form, including your workers222 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. You must request reimbursement by whichever date is later: (a) two years from the date the costs were incurred or (b) two years from the date the claim or medical condition is finally determined compensable. Name Claim number Mailing address Apt. # This is a new address ( ) - City State ZIP Phone P.O. Box City State ZIP TRANSPORTATION Start location End location Medical p rovider 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 m edication 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 Date TOTAL meals, lodging, and prescription reimbursement 440 - 3921 ( 1 /1 9 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Standard rates for the continental United States: L odging and meal rates effective Oct. 1, 201 8 226 Sept. 30, 201 9 ALL private vehicle mileage effective Jan. 1 , 201 9 5 8 cents per mile Breakfast $ 1 3 .75 Previous mileage rates: Lunch $ 1 3 .75 01/01/1 8 226 5 4 .5 cents per mile Dinner $ 27.50 01/01/17 226 53.5 cents per mile Lodging $ 94 .00 01/01/16 226 54 cents per mile 01/01/15 226 57.5 cents per mile Lodging rates do not include taxes. Room taxes are reimbursable in addition to the lodging allowance. Lodging and meal rates exceed the standard rate in the following Oregon loca tions: County Effective dates Max. lodging rate * Meal rate * * Clackamas All year $ 116 $ 56 Clatsop 10/1 226 6/30 $ 110 $ 71 7/1 226 8/31 $ 182 $ 71 9/1 226 9/30 $ 110 $ 71 Deschutes 10/1 226 5/31 $ 113 $ 61 6/1 226 8/31 $158 $61 9/1 226 9/30 $ 113 $ 61 Lane All year $ 115 $ 61 Lincoln 10/1 226 6/30 $ 107 $ 66 7/1 226 8/31 $ 151 $ 66 9/1 226 9/30 $107 $66 Multnomah 10/1 226 10/31 $ 184 $ 66 11/1 226 3/31 $ 150 $ 66 4 /1 226 9/30 $ 184 $ 66 Washington All year $ 133 $ 61 *Lodging rates do not include taxes. Room taxes are reimbursable in addition to the lodging allowance. **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