Form D-26 "Application for Reimbursement of Claim Related Travel Expenses" - Nevada

What Is Form D-26?

This is a legal form that was released by the Nevada Department of Business and Industry - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2004;
  • The latest edition provided by the Nevada Department of Business and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form D-26 by clicking the link below or browse more documents and templates provided by the Nevada Department of Business and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download Form D-26 "Application for Reimbursement of Claim Related Travel Expenses" - Nevada

Download PDF

Fill PDF online

Rate (4.8 / 5) 16 votes
APPLICATION FOR REIMBURSEMENT OF CLAIM RELATED TRAVEL EXPENSES
(Pursuant to NAC 616C.150)
Please type or print and provide all the information requested. Keep and be prepared to provide, if requested, any
receipts relating to your reimbursement request.
Name (Last, First, Middle Initial)
Claim Number
Present Address (P.O. Box, Apt. No., Street)
Social Security Number
City
State
Zip
Date of Injury
Residence at time of injury:
(For Insurer's Use Only)
[__] Approved
_______________
[__] Disapproved
Initials & Date
REPORT TRAVEL WEEKLY. See reverse side of this form for the regulations under which you may be
reimbursed for claim related travel. Be aware that any misrepresentation may be considered fraud and is in
violation of Nevada law.
Daily Expense Reimbursement
Mileage
Beginning Point
Enter Travel
Leave
Allowed
Meals
of Travel
Destination
Time
Travel
Miles One
(For Insurers Use
Lodging
Date
Address
Name/Address
Time
Way
Only)
B
L
D
TOTAL
MILES:
Total of
Miles X 2 @ $
.
per Mile =
I hereby certify that the record provided above is correct to the best of my knowledge and that all of the mileage for which I am requesting
reimbursement is related to or is for treatment authorized under Nevada Revised Statute (NRS) 616A to 616D, inclusive or chapter 617 of
NRS. I understand that the reporting of false information may disqualify me from receiving workers’ compensation benefits, and
may subject me to criminal and civil penalties. I certify under penalty of perjury that the above information is correct to the best of my
knowledge.
__________________________________________________
_________________________________
Injured Employee’s Signature
Date
D-26(1)
(Rev. 4/04)
APPLICATION FOR REIMBURSEMENT OF CLAIM RELATED TRAVEL EXPENSES
(Pursuant to NAC 616C.150)
Please type or print and provide all the information requested. Keep and be prepared to provide, if requested, any
receipts relating to your reimbursement request.
Name (Last, First, Middle Initial)
Claim Number
Present Address (P.O. Box, Apt. No., Street)
Social Security Number
City
State
Zip
Date of Injury
Residence at time of injury:
(For Insurer's Use Only)
[__] Approved
_______________
[__] Disapproved
Initials & Date
REPORT TRAVEL WEEKLY. See reverse side of this form for the regulations under which you may be
reimbursed for claim related travel. Be aware that any misrepresentation may be considered fraud and is in
violation of Nevada law.
Daily Expense Reimbursement
Mileage
Beginning Point
Enter Travel
Leave
Allowed
Meals
of Travel
Destination
Time
Travel
Miles One
(For Insurers Use
Lodging
Date
Address
Name/Address
Time
Way
Only)
B
L
D
TOTAL
MILES:
Total of
Miles X 2 @ $
.
per Mile =
I hereby certify that the record provided above is correct to the best of my knowledge and that all of the mileage for which I am requesting
reimbursement is related to or is for treatment authorized under Nevada Revised Statute (NRS) 616A to 616D, inclusive or chapter 617 of
NRS. I understand that the reporting of false information may disqualify me from receiving workers’ compensation benefits, and
may subject me to criminal and civil penalties. I certify under penalty of perjury that the above information is correct to the best of my
knowledge.
__________________________________________________
_________________________________
Injured Employee’s Signature
Date
D-26(1)
(Rev. 4/04)
Reimbursement for Costs of Transportation and Meals
Nevada Administrative Code (NAC) 616C.150 Eligibility and computation.
1. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for the cost
of transportation if he is required to travel 20 miles or more, one way, from:
(a) His residence to the place where he receives medical care; or
(b) His place of employment to the place where he receives medical care if the care is required during his normal working hours.
2. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for the cost
of transportation if he is required to travel 20 miles or more, one way, from his residence or place of employment to a place of hearing
designated by the insurer or the department of administration if the hearing concerns an appeal by the employer or insurer from a decision in
favor of the injured employee and the decision is upheld on appeal.
3. An injured employee who does not qualify for reimbursement under paragraph (a) or (b) of subsection 1 but is required to travel
a total of 40 miles or more in any one week for medical care or for attendance at the system's rehabilitation center is entitled to be
reimbursed for the cost of his transportation.
4. Except as otherwise provided in subsection 6, reimbursement for the cost of transportation must be computed at a rate equal to:
(a) The mileage allowance for state employees who use their personal vehicles for the convenience of the state; or
(b) The expense actually incurred by the injured employee for transportation, if the injured employee consents to reimbursement at
this rate and the expense is not greater than the amount to which the injured employee would otherwise be entitled pursuant to paragraph (a).
5. Except as otherwise provided in subsection 6, if an injured employee must travel before 7:00 a.m. or between 11:30 a.m. and
1:30 p.m. or cannot return to his home or place of employment until after 7:00 p.m., or any combination thereof, reimbursement for meals
required to be purchased must be computed at a rate equal to:
(a) That allowed for state employees; or
(b) The expense actually incurred by the injured employee for meals, if the injured employee consents to reimbursement at this
rate and the expense is not greater than the amount to which the injured employee would otherwise be entitled pursuant to paragraph (a).
6. The insurer, or those employers who have elected to provide accident benefits, shall reimburse an injured employee for his
expenses of travel if he is required to travel 50 miles or more, one way, from his residence or place of employment and is required to remain
away from his residence or place of employment overnight. Reimbursement must be computed at a rate equal to:
(a) The per diem allowance authorized for state employees; or
(b) The expenses actually incurred by the injured employee, whichever is less.
7. A claim for reimbursement of expenses governed by this section may be disallowed unless it is submitted to the insurer or
employer within 60 days after the expenses are incurred.
NAC 616C.153 Reimbursement for air fare. With the prior approval of the insurer or those employers who have elected to provide
accident benefits, an injured employee may be reimbursed for air fare where the time, distance, convenience or cost justifies his travel by
air.
NAC 616C.156 Limitations on reimbursements.
1. Unless otherwise directed or approved by the insurer, or the injured employee's treating physician or chiropractor, an injured
employee who chooses to obtain his medical services at a more distant place although adequate medical care is available at a closer place
may be reimbursed under NAC 616C.150 only for mileage to the closer place.
2. If a person moves outside this state or to a new location within this state for his own convenience after becoming an injured
employee, the maximum mileage for one direction for which he may be reimbursed is the mileage allowable before the move or 40 miles,
whichever is greater.
3. No reimbursement will be allowed for a person traveling with an injured employee unless there is a medical necessity that
precludes the injured employee from traveling alone. The medical necessity must be substantiated in writing by the injured employee's
treating physician or chiropractor.
Notice
An injured employee or any other person who knowingly makes a false statement or representation or knowingly conceals a material
fact in order to obtain or attempt to obtain any benefit may be subject to both civil penalties and criminal prosecution. If convicted, a
person forfeits all rights to workers’ compensation benefits and is liable for reasonable investigation costs of the insurer and attorney
general’s office, court costs, and restitution for payment or benefits fraudulently obtained. If the amount of the benefit or payment is
less than $250, the penalty is a misdemeanor which may result in county jail time not to exceed six months and a fine up to $1,000. If
the amount of the benefit or payment is $250 or more, the penalty is a category D felony which may result in imprisonment in the state
prison for at least 1 year and not more than 4 years and a fine up to $5,000. Insurance fraud includes, but is not limited to: 1) requesting
temporary total disability compensation or rehabilitation maintenance compensation while gainfully employed; 2) making false
statements about potential employer contacts, mileage or compensation, 3) misrepresenting facts concerning an industrial accident,
injury or illness to others such as an employer, insurer, physician or chiropractor, vocational rehabilitation counselor, and 4) filing an
invalid claim in order to obtain controlled substances.
If the employee is so severely injured that he is unable to complete this form, a friend, member of the family, labor representative, or
other agent may complete and sign for the injured employee.
D-26(2)
2
(Rev. 4/04)
Page of 2