Get I A Mileage Form

The I A Mileage Form is essential for individuals seeking reimbursement for medical travel expenses related to work-related injuries. This guide will provide you with clear and concise steps to complete the form online, ensuring all necessary information is included for successful processing.

Follow the steps to complete the I A Mileage Form online

1. Click ‘Get Form’ button to obtain the I A Mileage Form and open it in the online editor.
2. Begin by entering the claimant's first name, middle initial, and last name in the designated fields.
3. Input the claimant's Social Security number, ensuring accuracy in the format provided.
4. Record the date of injury in the appropriate section.
5. Enter the claimant's phone number, including area code.
6. Fill out the claim number as specified.
7. Provide the claimant's street address, city, state, and zip code in the respective fields.
8. In the 'Traveled From' section, list the date of travel along with the home address.
9. In the 'Traveled To' section, write the name and address of the medical provider, such as a doctor or therapist.
10. Enter the round trip mileage in the section provided, ensuring your calculations are accurate.
11. Fill in the total parking, bridge tolls, and public transportation expenses, attaching receipts where needed.
12. Add up all expenses to calculate total reimbursement amount.
13. Ensure that the statement affirming the accuracy of the expenses is acknowledged by signing and dating the form.
14. Once completed, save changes, download, print, or share the form as necessary.

Complete your I A Mileage Form online today to ensure prompt reimbursement for your medical travel expenses.