Get Texas Dir Form Dwc 053

Filling out the Texas Dir Form Dwc 053 online is an essential step for individuals seeking reimbursement for medical mileage expenses related to work injuries. This guide offers clear, step-by-step instructions to help users accurately complete the form and understand its components.

Follow the steps to successfully fill out the Texas Dir Form Dwc 053 online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the injured worker's name in the designated field labeled 'Injured worker's name / Nombre de la persona lesionada.' Ensure that the name is spelled correctly to avoid processing delays.
3. Fill in the claim number in the specified field. This number is crucial for associating the mileage reimbursement request with the correct case.
4. On the next part of the form, provide information about your travel for medical treatment. Indicate the date of travel using the field labeled 'Date / Fecha.' Ensure the format is consistent.
5. Complete the 'Traveled from / Viaje desde' section by including the address from which you traveled for treatment.
6. Next, fill in the 'Traveled to / Viaje a' field with the name and address of the medical provider (doctor, hospital, therapist, etc.) where treatment was received.
7. In the 'Round trip mileage / Millaje viaje redondo' section, enter the total mileage for the round trip. This should reflect the distance traveled to and from the medical appointment.
8. Calculate the reimbursement by multiplying the total miles by the mileage rate of $0.565 per mile. Enter this amount in the relevant field.
9. Fill in any additional costs incurred for tolls and parking in their respective sections, providing accurate amounts.
10. Finally, confirm the total reimbursement requested and ensure all figures add up correctly. Sign and print your name in the designated signature fields.
11. Once the form is completely filled out, save changes, download, print, or share your completed form as necessary. Remember to keep a copy for your records.

Start filling out your Texas Dir Form Dwc 053 online to ensure you receive the reimbursements you deserve.