"Mileage Reimbursement Form" - Florida

Mileage Reimbursement Form is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • Released on December 1, 2008;
  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download "Mileage Reimbursement Form" - Florida

Download PDF

Fill PDF online

Rate (4.3 / 5) 20 votes
MILEAGE REIMBURSEMENT
Social Security #:___________________________
**
PLEASE COMPLETE EACH SECTION OF THIS
Employee:
____________________________
FORM FOR EACH DAY MILEAGE REIMBURSEMENT
Employer:
____________________________
THAT IS BEING CLAIMED.
Date of Accident:____________________________
Claim Number: ______________________________
NAME AND ADDRESS OF PHYSICIAN
DATE(S)
ADDRESS CLAIMANT STARTED
ADDRESS OF FINAL DESTINATION
ROUND TRIP
OR MEDICAL FACILITY:
FROM
AFTER DR' S APPT
MILES
PLEASE DO NOT WRITE IN THIS SPACE
MILEAGE IS REIMBURSED AT $.445 CENTS PER MILE FOR TRAVEL TO/FROM AUTHORIZED MEDICAL PROVIDERS
AFTER 6/30/06..
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program files a statement of claim
containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234, FS.
Claimant's Signature:
Mail to: Division of Risk Management
__________________________________________
Bureau of State Employees' WC Claims
Mailing Address:
_______________________________________________
City/State/Zip:
P.O. Box 8020
_________________________________________________
Date:
Tallahassee, Florida 32314-8020
__________________________________________________
REV.12/2008
Save As
Reset/Clear Form
Print Form
8
MILEAGE REIMBURSEMENT
Social Security #:___________________________
**
PLEASE COMPLETE EACH SECTION OF THIS
Employee:
____________________________
FORM FOR EACH DAY MILEAGE REIMBURSEMENT
Employer:
____________________________
THAT IS BEING CLAIMED.
Date of Accident:____________________________
Claim Number: ______________________________
NAME AND ADDRESS OF PHYSICIAN
DATE(S)
ADDRESS CLAIMANT STARTED
ADDRESS OF FINAL DESTINATION
ROUND TRIP
OR MEDICAL FACILITY:
FROM
AFTER DR' S APPT
MILES
PLEASE DO NOT WRITE IN THIS SPACE
MILEAGE IS REIMBURSED AT $.445 CENTS PER MILE FOR TRAVEL TO/FROM AUTHORIZED MEDICAL PROVIDERS
AFTER 6/30/06..
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program files a statement of claim
containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234, FS.
Claimant's Signature:
Mail to: Division of Risk Management
__________________________________________
Bureau of State Employees' WC Claims
Mailing Address:
_______________________________________________
City/State/Zip:
P.O. Box 8020
_________________________________________________
Date:
Tallahassee, Florida 32314-8020
__________________________________________________
REV.12/2008
Save As
Reset/Clear Form
Print Form
8