Get NC IC Form 25T 2019-2023

FORM 25T 01/2019 PAGE 1 OF 1 NOTICE TO INJURED EMPLOYEE THIS FORM SHOULD BE RETURNED TO THE CARRIER AT THE ADDRESS ABOVE FOR PAYMENT. North Carolina Industrial Commission IC File ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp* Code Carrier Code Carrier File The Use of This Form Is Required Under the Provisions of the Workers Compensation Act Employer FEIN Employee s Name Address Employer s Address City State - Home Telephone Zip Telephone Number Insurance Carrier Work Telephone Carrier s Address Carrier s Telephone Number Fax Number Employees are entitled to reimbursement of 0. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers G*S* 97-25. DATE / NAME OF MEDICAL PROVIDER OTHER EXPENSES If overnight stay is necessary the following items will be approved as submitted* Receipts must be furnished for carrier s file. TOTAL MILES ROUNDTRIP CITY Total Miles Total motel expense actual up to 71. 20 per day in-state or 84. 10 per day out-of-state and 18. 90 in-state or 21. 60 out-of-state Dinner Total parking cab expense actual charge Total for other expenses X mileage rate Other expenses Total all expenses Prior mileage rates are as follows a 0. 545 for 2018 b 0. 535 for 2017 c 0. 54 for 2016 d 0. 575 for 2015 e 0. 56 for 2014 I hereby certify that I have incurred all expenses listed above as a result of my workers compensation injury. Employee signature Carrier s approval Employee Mail your bill in duplicate promptly to employer and/or Employer or Carrier/Administrator Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval* Pay and retain copy in carrier s file. North Carolina Industrial Commission IC File ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp* Code Carrier Code Carrier File The Use of This Form Is Required Under the Provisions of the Workers Compensation Act Employer FEIN Employee s Name Address Employer s Address City State - Home Telephone Zip Telephone Number Insurance Carrier Work Telephone Carrier s Address Carrier s Telephone Number Fax Number Employees are entitled to reimbursement of 0. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers G*S* 97-25. DATE / NAME OF MEDICAL PROVIDER OTHER EXPENSES If overnight stay is necessary the following items will be approved as submitted* Receipts must be furnished for carrier s file. .