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The Workers’ Compensation Mileage Form provides documentation of the miles traveled to seek authorized medical care for a work-related injury. The form has three sections:
Section 1: To Be Completed by the Employee
You need to ensure that to provide the following information:
- Name and address of the employee
- CARO case number (if known)
- Date of injury
- Name of state agency
When filling out the form, you should include the dates you traveled, what city you departed from, what city you traveled to, and the number of round-trip miles traveled to seek medical care for the injury acquired. Ensure you sign the form before submission.
Section 2: To Be Completed by the Medical Care Provider
The medical provider should complete this section of the form each time a treatment is provided in order to determine the mileage traveled. The medical care provider should fill in their name and office address and sign and date the form.
Section 3: To the Completed by CARO
The Central Accident Reporting Office (CARO) completes this section of the form when payments are processed based on the state mileage allowance rate in effect on the date the employee traveled for medical care.
Regularly submit your mileage reimbursement form to CARO, together with any receipts for other travel expenses. You or your state agency can submit the form and supporting documents to CARO.
If you suffer a workers’ compensation injury, you may be entitled to reimbursement for medical-related travel expenses. These include:
- Bus fares
- Train tickets
- Highway tolls
- Bridge tolls
It is, therefore, important that you keep receipts for any expenses incurred while receiving treatment for a work-related injury.
The weekly compensation injured workers can receive is based on two-thirds of their average weekly wage, subject to the statutory maximum as of the date of the injury. The maximum weekly compensation rate for a permanent partial disability is less than the maximum for the total disability because the disability is partial and not complete.