Get Form 957

Filling out the Form 957 online can be a straightforward process if approached step by step. This guide aims to assist users in completing the form accurately to request reimbursement for travel expenses related to medical care.

Follow the steps to successfully complete the Form 957 online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the claimant's full name, including last name, first name, and middle initial in the designated field.
3. Enter the claimant's case or claim number in the appropriate section.
4. If a different payee is submitting the request, enter their full name, including last name, first name, and middle initial.
5. Fill in the payee’s address, ensuring to include the street or route, city, state, and zip code.
6. For medical travel information, complete a separate block for each medical facility visited on the same day. Provide the date of travel and specify whether it is one-way or round trip.
7. Indicate the travel from and travel to locations by marking the appropriate boxes.
8. Enter the name and address of the medical facilities visited in the required fields.
9. List the expenses you are claiming reimbursement for, marking each box accordingly and providing the amount spent.
10. If traveling by private automobile, enter the total number of miles traveled.
11. Obtain the required signature from a physician or designee for black lung-related treatments as specified.
12. Sign and date the form to certify that the information provided is accurate, ensuring that the claimant’s full name and social security number appear on all original receipts attached.
13. Once completed, users can save changes, download the form, print it, or share it as needed.

Start filling out your Form 957 online today for prompt reimbursement processing.