Get CA e3065 2013

California law requires the following to appear on this form Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to ines and coninement in state prison. Please note Mileage for reasonable travel to the pharmacy parking bridge tolls and public transportation costs should also be included. Attach receipts and send this form to State Compensation Insurance Fund. Keep a copy for your records. Mail to your assigned claims adjuster provided on your claim correspondence or mail to one of these State Fund Claims Processing Centers Injured s Name / Nombre de la Persona Lesi nada - PO BOX 65005 FRESNO CA 93650 - PO BOX 3171 SUISUN CITY CA 94585 Claim Number / N mero de Reclamo Medical Mileage Expense Form Forma de Gastos por Distancia Recorrida por Visitas M dica You are entitled to reimbursement of medical travel expense incurred because of your industrial injury. Complete this form to request reimbursement of medical travel expense. Mileage rates are different depending on the day you traveled* We will calculate the total due using the miles traveled* Please see example below. Rate For Travel / Tarifa Para Viajes 1/01/2013 - Current 56. 5 cents/centavos 7/01/2008 - 12/31/2008 1/01/2008 - 06/30/2008 34. 0 cents/centavos Usted tiene derecho a recibir reembolso por gastos de viaje por visitas m dicas incurridos debido a la lesi n sufrida en el trabajo. Llene este formulario para solicitar el reembolso de gastos de viaje m dicos. Las tarifas para millaje son diferentes seg n el d a que usted viaj. Vamos a calcular el total adeudado usando las millas que usted viaj. Por favor vea el ejemplo abajo. Las leyes de California establecen que la siguiente declaraci n aparezca en este formulario Cualquier persona que a sabiendas presente reclamos falsos o fraudulentos para el pago de una p rdida ser culpable de un delito y se le podr a multar y encarcelar en la penitenciar a estatal* Por favor de notar Millaje razonable para viajar a la farmacia aparcamiento peajes de puentes los costos del transporte p blico tambi n deber a incluirse. Adjuntar recibos y env e este formulario a State Compensation Insurance Fund* Guarde una copia para sus archivos. Example Ejemplo 7/1/11 Traveled from include address Traveled to include name and address of doctor hospital therapist etc* Round trip mileage/ Viaje desde incluya direcci n Date / Fecha Viaje a incluya nombre y direcci n del medico hospital terapeuta etc* Millaje viaje redondto 1515 Maple San Francisco Dr. Sherman 190 Oak 14 mi For State Fund Use 14 mi x. 555 c Total Parking and/or Tolls attach receipts Estaccionamiento y/o Peaje incluye recibos Total Public Trans / Other Transporte P blico / Otros Total SIGNATURE / FIRMA PRINT NAME / IMPRIMA SU NOMBRE DATE / FECHA e3065 REV. Mail to your assigned claims adjuster provided on your claim correspondence or mail to one of these State Fund Claims Processing Centers Injured s Name / Nombre de la Persona Lesi nada - PO BOX 65005 FRESNO CA 93650 - PO BOX 3171 SUISUN CITY CA 94585 Claim Number / N mero de Reclamo Medical Mileage Expense Form Forma de Gastos por Distancia Recorrida por Visitas M dica You are entitled to reimbursement of medical travel expense incurred because of your industrial injury. Complete this form to request reimbursement of medical travel expense. Mileage rates are different depending on the day you traveled* We will calculate the total due using the miles traveled* Please see example below. .