"Mileage Reimbursement Form" - Kansas

Mileage Reimbursement Form is a legal document that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas.

Form Details:

  • Released on May 5, 2017;
  • The latest edition currently provided by the Kansas Department of Health & Environment;
  • 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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MILEAGE REIMBURSEMENT
                                                                   
Official  Use Only   Rev 5/5/17
Mail To:   State Self Insurance Fund
900 SW Jackson, Room 951‐S
Landon State Office Building
Topeka, Kansas 66612‐1251
FAX: 785‐296‐6995
PHONE: 785‐296‐2364
NAME:
HOME ADDRESS:
CITY:                            
STATE, ZIP:
 EMPLOYEE ID# :              
Submit your mileage for all trips that exceed 5 miles round trip. The purpose of the trip must be for medical care for your injury or to purchase medically related items, 
such as prescriptions. Please submit this mileage request and any toll fee receipts on a monthly basis until your claim is closed.
TOTAL
(Enter exact address)
(Enter exact address)
DATE:
MILES:
FROM WHAT LOCATION:
TO WHAT D PURPOSE OF TRIP:
MILEAGE REIMBURSEMENT
                                                                   
Official  Use Only   Rev 5/5/17
Mail To:   State Self Insurance Fund
900 SW Jackson, Room 951‐S
Landon State Office Building
Topeka, Kansas 66612‐1251
FAX: 785‐296‐6995
PHONE: 785‐296‐2364
NAME:
HOME ADDRESS:
CITY:                            
STATE, ZIP:
 EMPLOYEE ID# :              
Submit your mileage for all trips that exceed 5 miles round trip. The purpose of the trip must be for medical care for your injury or to purchase medically related items, 
such as prescriptions. Please submit this mileage request and any toll fee receipts on a monthly basis until your claim is closed.
TOTAL
(Enter exact address)
(Enter exact address)
DATE:
MILES:
FROM WHAT LOCATION:
TO WHAT D PURPOSE OF TRIP: