Get Brickstreet Travel Form

The Brickstreet Travel Form is essential for users seeking reimbursement for travel expenses related to medical examinations and procedures. This guide will provide clear, step-by-step instructions to help you accurately complete the form online.

Follow the steps to fill out the Brickstreet Travel Form online.

1. Press the ‘Get Form’ button to obtain the Brickstreet Travel Form and open it for editing.
2. In the first section, enter the claimant's name, including the first, middle, and last name as it appears in official communications.
3. Next, provide the complete mailing address of the claimant, including street or P.O. Box, city, state, and zip code.
4. Input the claimant’s Social Security number in the designated field.
5. Record the date of injury, which is important for occupational pneumoconiosis or disease claims.
6. Enter the claim number assigned by Brickstreet Insurance in the specified section.
7. Include the provider's name by printing it clearly to ensure proper identification.
8. If applicable, write the authorization number for services that require prior authorization.
9. Fill in the address of the point of departure, ensuring to include the full physical address or the closest route number.
10. Provide the destination address, which is the service provider's office address including all relevant details.
11. Specify the time of departure from the residence and ensure to note whether it's AM or PM.
12. Indicate the time of return to the residence, similarly noting AM or PM.
13. Describe the purpose of travel succinctly in the provided field.
14. Document the date of travel as well as any expenses incurred, ensuring one type of expense per line.
15. Refer to the procedure code list on the front of the form and input the relevant code in the corresponding field.
16. Clearly describe the expense in the designated description field.
17. Indicate the units or quantity in the respective area.
18. All vouchers must include the service provider's signature to validate the claim.
19. Sign and date the form in the claimant’s signature section to confirm the submission.
20. Calculate and enter the total charges for all claimed expenses.
21. If applicable, the employer should complete the employer's section for any lost wages.
22. After filling out the form, save your changes. You can then download, print, or share the completed form as necessary.

Complete your Brickstreet Travel Form online today to ensure timely reimbursement for your travel expenses.