工人賠償表格

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醫療里程表

Medical Mileage Expense Form 2025

For mileage that occurs in 2025, the rate is 70 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

Medical Mileage Expense Form 2024

For mileage that occurs in 2024, the rate is 67 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

Medical Mileage Expense Form 2023

For mileage that occurs in 2023, the rate is 65.5 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

Medical Mileage Expense Form 2022

For mileage that occurs after 7/1/2022, the rate is 62.5 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claims examiner.