Month, Day, Year
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FARA will pay reasonable mileage reimbursement for the miles you travel to and from medical appointments for treatment of your work injury. To receive reimbursement, please complete this form and fax or mail it to us. We will verify that you attended each appointment. We will also verify the distance from your home address to the doctor's office using MapQuest.
Please print. If we cannot read this form or if information is missing, payment could be delayed. Feel free to make additional copies as needed.
Employee Name: Date: Home Address: Claim No. City/State/Zip: Employer: Phone # Work Address: Date of Injury: City/State/Zip:
Round From Date Trip Miles (Circle One) Facility Name: HOME WORK Doctor Name: HOME WORK Address: HOME WORK City/State/Zip: HOME WORK Phone # HOME WORK Total Mileage:
Round From Date Trip Miles (Circle One) Facility Name: HOME WORK Doctor Name: HOME WORK Address: HOME WORK City/State/Zip: HOME WORK Phone # HOME WORK Total Mileage:
Round From Date Trip Miles (Circle One) Facility Name: HOME WORK Doctor Name: HOME WORK Address: HOME WORK City/State/Zip: HOME WORK Phone # HOME WORK Total Mileage: Grand Total:
Signature: Date: