BI-102 01/08 Return completed form to: Claimant Travel Voucher BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 TRAVEL VOUCHERS MUST BE FILED WITHIN SIX MONTHS OF THE DATE OF TRAVEL 1. Claimant’s Name (First, Middle, Last) 2. Claimant’s Address (Street or P.O. Box, City, State, Zip) 3. Claimant’s Social Security Number: 4. Date of Injury 5. Claim Number 6. Provider’s Name (please print) 7. Authorization Number 8. Address of Point of Departure (need physical address or closest route number) 9. Address of Point of Destination 11. Time of Return 10. Time of Departure a.m. 12. Purpose of Travel p.m. a.m. p.m. Medical procedure codes to be used below in column 14: Code Description Code Description Code Description X0910 Hotel / Motel X9910 Mileage (Occupational Pneumoconiosis) X0930 Air Travel X0915 *Meals X0920 Mileage X0935 Bus / Train X9911 *Meals (Occupational Pneumoconiosis) X0925 Parking / Tolls X0300 Voc. Rehab (mileage for retraining) X0922 Reimbursement for IME travel X0921 Claimant travel 2nd physician same day mileage FEDTR Federal Black Lung - Travel Hotel/Motel stay and Air/Bus/Train travel require prior authorization. Receipts must be attached when seeking reimbursement for all services other than mileage. *Meals are reimbursed for authorized OVERNIGHT travel only. 13. Date 18. Service Provider’s Signature 14. Procedure Code 15. Description 16. Units / Quantity 19. Claimant’s Signature Date 17. Charges 20. Total Charges The present employer is to complete the section below only if the claimant has lost wages in order to appear for a medical examination requested by BrickStreet Insurance. (Not for routine medical treatment) 21. Employer’s Business Name, Address and Phone Number EMPLOYER 22. Date(s) of Lost Wages 23. Number Hours of Wages Lost Date(s) of Lost Wages 24. Hourly Wage 25. Amount of Lost Wages Number Hours of Wages Lost X = Hourly Wage X Employer’s Signature Title Amount of Lost Wages = Date American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING CLAIMANT TRAVEL VOUCHER Each travel voucher can contain expenses for only ONE CLAIM and visits to ONLY ONE SERVICE PROVIDER. If information is wrong, missing or illegible, the form will be returned to you. 1. CLAIMANT’S NAME: Your full name as it appears on the letters we send you. 2. CLAIMANT’S ADDRESS: Your full mailing address including zip code. 3. CLAIMANT’S SOCIAL SECURITY NUMBER: Your Social Security Number. 4. DATE OF INJURY: In an occupational pneumoconiosis or disease claim, this is the date of last exposure. 5. CLAIM NUMBER: The number assigned to your claim by BrickStreet Insurance. 6. PROVIDER’S NAME: The service provider that you went to see. 7. AUTHORIZATION NUMBER: Services that require prior authorization must have this number. This number appears on the letter sent to you granting authorization for the service or procedure. There is no number for an OP Board examination. 8. ADDRESS OF THE POINT OF DEPARTURE: BrickStreet reimburses for mileage from the claimant’s residence. This street address must be written completely including street, city, state, and zip code. (No. P.O. Boxes) 9. ADDRESS OF POINT OF DESTINATION: This is the complete address of the service provider’s office to which you traveled. Include the street, city and zip code. (No P.O. Boxes) 10. TIME OF DEPARTURE: This is the time you left your residence (the address of the point of departure). 11. TIME OF RETURN: This is the time you returned to your residence. 12. PURPOSE OF TRAVEL: The reason you made the trip. 13. DATE: The date of the travel, meal, lodging etc. Put only one type of expense on each line. Note: Travel vouchers must be filed with BrickStreet Insurance within six months of the date of travel. 14. PROCEDURE CODE: The code list is on the front of the form in the first shaded area. Find the code for the expense for which you are billing and put in this block. 15. DESCRIPTION: Explain the type of expense for which you are billing. 16. UNITS: The number of miles traveled. 17. CHARGES: The total charges for the line item. 18. SERVICE PROVIDER’S SIGNATURE: All vouchers must be signed by the service provider you went to see. 19. CLAIMANT’S SIGNATURE AND DATE: This is your signature and the date that you are sending this form to us. 20. TOTAL CHARGES: This is total of all the amounts in the “charges” column. 21. EMPLOYER’S BUSINESS NAME, ADDRESS AND PHONE NUMBER: This is the employer’s information. CLAIMANT: DO NOT FILL OUT BLOCKS 22 through 26. This section is completed by your current employer if you missed work and lost wages because you were attending a medical examination requested by BrickStreet Insurance. After this form is completed, make a copy of the form and any receipts for your records and send the form to BrickStreet Insurance at the address listed on the front of the form. *NOTE: Meal reimbursement will be made only if the claimant has been authorized for overnight travel. *NOTE: Lost wages will be reimbursed only when the claimant appears for a medical examination requested by BrickStreet Insurance. American LegalNet, Inc. www.FormsWorkflow.com