Get F245 145 000
(Please print) Claim No. Name (Last, First, Middle Initial) Date of injury Home address (not PO Box) Apt # City State Social Security No. (for ID only) ZIP Phone no. Reason for travel: (check one) Medical visit or treatment Vocational services Attending retraining class (attach copy of Transportation Encumbrance form F245-375-000 signed by Vocational Counselor) Travel Information Instructions and example on back. A. B. C. D. E. F. G. Date Travel code From To Provider nam.
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