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Get NY C-257 2010

NATURE OF EXPENSE / TIPO DE GASTOS Continue on Reverse. C-257 9-10 SOCIAL SECURITY NO. DATE / FECHA - AMOUNT / CANTIDAD Sigue al dorso. THE WORKERS COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. LA JUNTA DE COMPENSACI N OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR. NYS Workers Compensation Board Centralized Mailing PO Box 5205 Binghamton NY 13902-5205 Statewide Fax Line 877-533-0337 C-257 9-10 Reverse Address for Email Filing wcbclaimsfiling wcb. State of New York WORKERS COMPENSATION BOARD CLAIMANT S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT CLAIMANT S NAME WCB CASE NO. RESIDENTIAL ADDRESS In connection with the above workers compensation case you are entitled to be reimbursed for 1 drugs crutches or any apparatus properly prescribed by your doctor and for 2 fares automobile mileage or other necessary expenses going to and from your doctor s office or the hospital* To help you keep a record of such expenses we have provided this form* In order to help insure that you are properly reimbursed list each item of expense below-whether or not you obtained a receipt wherever possible obtain receipts. Submit the completed form and copies of all receipts or bills to the workers compensation insurance carrier or to your employer if self-insured and to the Workers Compensation Board. See Board address on reverse. It is suggested that you retain a copy of the receipts and bills for your records. MAILING ADDRESS IF DIFFERENT En relaci n con el caso de compensaci n para trabajadores antes mencionado usted tiene derecho a recibir un reembolso por 1 medicamentos muletas o cualquier aparato indicado como corresponde por su m dico y 2 tarifas millaje de autom vil u otros gastos necesarios para trasladarse desde y hasta el consultorio de su m dico u hospital* Le proporcionamos este formulario para ayudarlo a llevar un registro de esos gastos. Con el objetivo de garantizar que usted reciba el reembolso correspondiente enumere cada tem de gasto a continuaci n tenga o no un recibo por ese gasto siempre que sea posible intente obtener un recibo. Env e el formulario completo y copias de todos los recibos o facturas a la compa a de seguros de compensaci n para trabajadores o a su empleador en caso de que tenga un seguro propio y a la Junta de Compensaci n para Workers copia de los recibos y facturas para sus registros. State of New York WORKERS COMPENSATION BOARD CLAIMANT S RECORD OF MEDICAL AND TRAVEL EXPENSES AND REQUEST FOR REIMBURSEMENT CLAIMANT S NAME WCB CASE NO. RESIDENTIAL ADDRESS In connection with the above workers compensation case you are entitled to be reimbursed for 1 drugs crutches or any apparatus properly prescribed by your doctor and for 2 fares automobile mileage or other necessary expenses going to and from your doctor s office or the hospital* To help you keep a record of such expenses we have provided this form* In order to help insure that you are properly reimbursed list each item of expense below-whether or not you obtained a receipt wherever possible obtain receipts. .

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