Request for Reimbursement of Expenses
|Request for Reimbursement of Expenses |
|Complete this form, including your workers’ 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 provider |Trip miles |Date | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | [pic] |
| |TOTAL miles |
|MEALS |
|Date |Breakfast |
|LODGING |
|Hotel/motel name |Location |Date |Cost | |
| | | |$ | |
| | | |$ | |
| | | |$ |$[pic] |
| |TOTAL lodging |
| |reimbursement |
|PRESCRIPTIONS |
|Name of medication |Doctor |Date |Cost | |
| | | |$ | |
| | | |$ | |
| | | |$ | |
| | | |$ |$[pic] |
| |TOTAL prescription |
| |reimbursement |
| |
| | |
|By my signature, I certify that all information I have given in this request for reimbursement is true and | | [pic] |
|contains no false statements or misrepresentations. | | |
| | |TOTAL miles |
| |
| | | | | |$[pic] |
|Signature of worker | |Date | |TOTAL meals, |
| | | | |lodging, and |
| | | | |prescription |
| | | | |reimbursement |
|440-3921 (10/21/DCBS/WCD/WEB) | |
|Standard rates for the continental United States: |
|Lodging and meal rates effective Oct. 1, 2021|ALL private vehicle mileage effective Jan. 1, 2021 |
|– Sept. 30, 2022 |56 cents per mile |
|Breakfast |$14.75 | |Previous mileage rates: |
|Lunch |$14.75 | |01/01/20 – 57.5 cents per mile |
|Dinner |$29.50 | |01/01/19 – 58 cents per mile |
|Lodging |$96.00 | |01/01/18 – 54.5 cents per mile |
| | | |01/01/17 – 53.5 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 locations: |
|County |Effective dates |Max. lodging rate* |Meal rate** |
|Clackamas |10/01/21 – 05/31/22 |$115 |$64 |
| |06/01/22 – 08/31/22 |$138 |$64 |
| |09/01/22 – 09/30/22 |$115 |$64 |
|Clatsop |10/01/21 – 06/30/22 |$110 |$69 |
| |07/01/22 – 08/31/22 |$182 |$69 |
| |09/01/22 – 09/30/22 |$110 |$69 |
|Deschutes |10/01/21 – 05/31/22 |$115 |$64 |
| |06/01/22 – 08/31/22 |$161 |$64 |
| |09/01/22 – 09/30/22 |$115 |$64 |
|Lane |10/01/21 – 09/30/22 |$108 |$64 |
|Lincoln |10/01/21 – 06/30/22 |$114 |$69 |
| |07/01/22 – 08/31/22 |$162 |$69 |
| |09/01/22 – 09/30/22 |$114 |$69 |
|Multnomah |10/01/21 – 10/31/21 |$182 |$74 |
| |11/01/21 – 05/31/22 |$152 |$74 |
| |06/01/22 – 09/30/22 |$182 |$74 |
|Washington |10/01/21 – 09/30/22 |$136 |$64 |
|*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.
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