"Workers' Compensation Mileage Reimbursement Request" - Georgia (United States)

Workers' Compensation Mileage Reimbursement Request is a legal document that was released by the Georgia Department of Administrative Services - a government authority operating within Georgia (United States).

Form Details:

  • Released on November 7, 2018;
  • The latest edition currently provided by the Georgia Department of Administrative Services;
  • 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 Georgia Department of Administrative Services.

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Workers’ Compensation
Mileage Reimbursement Request
EMPLOYEE
EMPLOYEE
ADDRESS
CLAIM #
DATE OF INJURY
Purpose
Round
Date of Visit
Name of Doctor of Facility
of
Trip
Visit
Mileage
My signature on this form indicates a true representation of mileage and medical trips. I understand any
misrepresentation on mileage will be considered Fraud under the Ga Workers' Compensation Statute and
subject me to possible fines and imprisonment under Georgia Statute.
Signature
Date:
Risk Management Services
Phone: 404-656-6245
200 Piedmont Avenue SE  Suite 1220 West Tower  Atlanta, Georgia 30334-9010
Fax: 404-657-1188
www.doas.ga.gov
Revision 2018
Workers’ Compensation
Mileage Reimbursement Request
EMPLOYEE
EMPLOYEE
ADDRESS
CLAIM #
DATE OF INJURY
Purpose
Round
Date of Visit
Name of Doctor of Facility
of
Trip
Visit
Mileage
My signature on this form indicates a true representation of mileage and medical trips. I understand any
misrepresentation on mileage will be considered Fraud under the Ga Workers' Compensation Statute and
subject me to possible fines and imprisonment under Georgia Statute.
Signature
Date:
Risk Management Services
Phone: 404-656-6245
200 Piedmont Avenue SE  Suite 1220 West Tower  Atlanta, Georgia 30334-9010
Fax: 404-657-1188
www.doas.ga.gov
Revision 2018