Follow the steps to fill out the Medical Travel Refund Request form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Enter the claimant's full name in the designated field, including last name, first name, and middle initial.
3. Provide the case or claim number in the next field. Ensure this number is accurate, as it directly relates to the claimant's reimbursement request.
4. If a different payee is receiving reimbursement, enter their name in the appropriate section, including last name, first name, and middle initial. Ensure you have the necessary authorization for this individual.
5. Input the complete address for the payee in the corresponding field, making sure to include street or RFD, city, state, and zip code.
6. For each medical facility visited, complete a section with the date of travel, travel route (from and to), and the name and address of the medical facility.
7. Indicate the types of expenses incurred by marking the corresponding boxes and entering the associated costs. This includes taxi fares, lodging, meals, and any other expenses.
8. If applicable, record the total number of miles traveled by personal vehicle in the appropriate area if claiming reimbursement for private auto travel.
9. Obtain the physician’s signature or facsimile, essential for claims related to black lung services, to verify the services rendered.
10. Finally, certify all provided information is correct by signing and dating the form, ensuring accuracy before submission.
11. Upon completion, save your changes and proceed to download, print, or share the form as needed, ensuring you attach all original receipts where required.

Start completing your Medical Travel Refund Request form online now.