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044 TravelExpenseForm044.pdf (08-2019) Reimbursement for Health Care Travel Expenses Pursuant to Idaho Code 72-432(1) Name of Injured Worker: ______________________________________________ Claim #: ______________________ SSN: _______________________ Address: ___________________________________________________________ ___________________________________________________________ Phone: _______________________ 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 or by contacting the Idaho Industrial Commission. 4. You must attach to this form a copy of a bill or receipt showing that each visit occurred. Date of Visit Name of Provider of Health Care Services Purpose Of Visit Total Mileage (Please Type or Print Neatly) Claimant's Signature Date Signed Date Received by Surety Submit by one of these methods: Upload saved file to our website at www.idahosif.org/document/upload Email it as an attachment to [email protected] Mail to: State Insurance Fund; P.O. Box 83720; Boise, ID 83720-0044 PO Box 83720 Boise, ID 83720-0044 208-332-2100 www.idahosif.org

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Page 1: Reimbursement for Health Care Travel Expenses

044 TravelExpenseForm044.pdf (08-2019)

Reimbursement for Health Care Travel ExpensesPursuant to Idaho Code 72-432(1)

Name of Injured Worker: ______________________________________________

Claim #: ______________________ SSN: _______________________

Address: ___________________________________________________________

___________________________________________________________

Phone: _______________________

1. Use this form when claiming reimbursement for travel expenses incurred while pursuing reasonableor 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, youshould report the total mileage for each round trip. You are expected to take the shortest practicalroute of travel.

3. Reimbursement shall be made at the mileage rate allowed by the State Board of Examiners for stateemployees. The current rate for this mileage is available through your insurance company or bycontacting the Idaho Industrial Commission.

4. You must attach to this form a copy of a bill or receipt showing that each visit occurred.

Date of Visit Name of Provider of Health Care Services Purpose Of Visit Total

Mileage

(Please Type or Print Neatly)

Claimant's Signature Date Signed Date Received by Surety

Submit by one of these methods: Upload saved file to our website at www.idahosif.org/document/upload Email it as an attachment to [email protected] Mail to: State Insurance Fund; P.O. Box 83720; Boise, ID 83720-0044

PO Box 83720 Boise, ID 83720-0044 208-332-2100 www.idahosif.org

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