Get F 245 224 000 Form

Completing the F 245 224 000 form online is a crucial step in ensuring you receive reimbursement for travel and wage expenses related to your independent medical exam. This guide will provide clear, step-by-step instructions to help you navigate the form with ease.

Follow the steps to fill out your form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully review the instructions on the form. This will help you understand what information is required to complete each section.
3. In the 'Injured Worker Information' section, input your name, date of injury, home address, social security number (for ID only), and phone number.
4. Fill out the 'Travel Information' section. In Column A, list the date of each trip. In Column B, find and enter the appropriate travel code that describes your travel expense.
5. In Column C, write the city you were traveling from. In Column D, input the city you traveled to for your medical exam, along with the name of the doctor you will see.
6. In Column E, record the total number of miles you traveled round trip. Ensure that you use the shortest direct route from your home.
7. In Column F, detail any expenses related to food, lodging, fares, parking, or wages. Enter the dollar amount for each, ensuring you attach all relevant receipts.
8. Once all information is filled out, review the form for accuracy. Make sure it is complete and clear.
9. Sign the form to confirm that the information provided is truthful and that you understand the instructions.
10. Save your changes, then download or print the form. Submit your completed form and receipts to the Department of Labor & Industries at the specified address.

Complete your documents online today to ensure timely processing of your reimbursement.