MILEAGE REIMBURSEMENT - Florida Department of Financial ...
MILEAGE REIMBURSEMENT**PLEASE COMPLETE EACH SECTION OF THIS FORM FOR EACH DAY MILEAGE REIMBURSEMENT THAT IS BEING CLAIMED. (ALL MILES ARE SUBJECT TO VERIFICATION BEFORE PROCESSING.) Claim Number: _________________________________Employee: _____________________________________Employer: _____________________________________Date of Accident: _______________________________Adjuster: ______________________________________DATE(S)ADDRESS CLAIMANT STARTED FROMNAME AND ADDRESS OF PHYSICIAN OR MEDICAL FACILITY:ADDRESS OF FINAL DESTINATION AFTER DR’S APPTROUND TRIP MILESPLEASE DO NOT WRITE IN THIS SPACEMILEAGE IS REIMBURSED AT $.445 CENTS PER MILE FOR TRAVEL TO/FROM AUTHORIZED MEDICAL PROVIDERSAny person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.ClaimantsSignature: ______________________________________Date: __________________________________________Mail to: Division of Risk ManagementBureau of State Employees' WC Claims P.O. Box 8020Tallahassee, Florida 32314-8020REV. 7/2014 D14-866 ................
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