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Get NC IC Form 25T 2011

FORM 25T 12/2013 PAGE 1 OF 1 FOR ASSISTANCE CALL N.C. INDUSTRIAL COMMISSION MAIN TELEPHONE 919 807-2500 WORKERS COMPENSATION INFORMATION SPECIALISTS 800 688-8349. 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. 56 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2014. 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 / TOTAL MILES ROUNDTRIP CITY 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 motel expense 45. 00 per day Total Miles 8. 00 Lunch and 14. 00 Dinner X mileage rate Total parking cab expense actual charge Other expenses Total for other expenses Total all expenses Prior mileage rates are as follows a 0. 565 for January 1 2013 - December 31 2013 b 0. 555 for July 1 2011 - December 31 2012 c 0. 51 for January 1 2011 - June 30 2011 d 0. 50 for 2010 e 0. 55 for 2009 f 0. 585 for July 1 2008 - December 31 2008 g before January 18 2006. 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. 56 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2014. 56 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2014. 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 / TOTAL MILES ROUNDTRIP CITY 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. .

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