Form C-257 "Claimant's Record of Medical and Travel Expenses and Request for Reimbursement" - New York

Form C-257 is a New York State Workers' Compensation Board form also known as the "Form C-257 "claimant's Record Of Medical And Travel Expenses And Request For Reimbursement" - New York". The latest edition of the form was released in September 1, 2010 and is available for digital filing.

Download an up-to-date Form C-257 in PDF-format down below or look it up on the New York State Workers' Compensation Board Forms website.

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Download Form C-257 "Claimant's Record of Medical and Travel Expenses and Request for Reimbursement" - New York

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State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES
AND REQUEST FOR REIMBURSEMENT
CLAIMANT'S NAME
WCB CASE NO.
SOCIAL SECURITY NO.
RESIDENTIAL ADDRESS
MAILING ADDRESS (IF DIFFERENT)
In connection with the above workers compensation
En relación con el caso de compensación para
case, you are entitled to be reimbursed for (1) drugs,
trabajadores antes mencionado, usted tiene derecho a
crutches or any apparatus properly prescribed by your
recibir un reembolso por (1) medicamentos, muletas o
doctor and for (2) fares, automobile mileage or other
cualquier aparato indicado como corresponde por su
necessary expenses going to and from your doctor's
médico y (2) tarifas, millaje de automóvil u otros gastos
office or the hospital.
necesarios para trasladarse desde y hasta el consultorio
de su médico u hospital.
To help you keep a record of such expenses we have
Le proporcionamos este formulario para ayudarlo a
provided this form. In order to help insure that you are
llevar un registro de esos gastos. Con el objetivo de
properly reimbursed, list each item of expense below--
garantizar
que
usted
reciba
el
reembolso
whether or not you obtained a receipt (wherever
correspondiente, enumere cada ítem de gasto a
possible obtain receipts). Submit the completed form
continuación, tenga o no un recibo por ese gasto
and copies of all receipts or bills to the workers'
(siempre que sea posible, intente obtener un recibo).
compensation
insurance
carrier
(or
to
your
Envíe el formulario completo y copias de todos los
employer, if self-insured) and to the Workers'
recibos o facturas a la compañía de seguros de
Compensation Board.
(See Board address on
compensación para trabajadores (o a su empleador en
reverse.) It is suggested that you retain a copy of the
caso de que tenga un seguro propio) y a la Junta de
receipts and bills for your records.
Compensación
para
Trabajadores
(Workers'
Le sugerimos que guarde una
Compensation Board
copia de los recibos y facturas para sus registros.
NATURE OF EXPENSE / TIPO DE GASTOS
DATE / FECHA
AMOUNT / CANTIDAD
Continue on Reverse.
-
Sigue al dorso.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-257 (9-10)
LA JUNTA DE COMPENSACIÓN OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR.
State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES
AND REQUEST FOR REIMBURSEMENT
CLAIMANT'S NAME
WCB CASE NO.
SOCIAL SECURITY NO.
RESIDENTIAL ADDRESS
MAILING ADDRESS (IF DIFFERENT)
In connection with the above workers compensation
En relación con el caso de compensación para
case, you are entitled to be reimbursed for (1) drugs,
trabajadores antes mencionado, usted tiene derecho a
crutches or any apparatus properly prescribed by your
recibir un reembolso por (1) medicamentos, muletas o
doctor and for (2) fares, automobile mileage or other
cualquier aparato indicado como corresponde por su
necessary expenses going to and from your doctor's
médico y (2) tarifas, millaje de automóvil u otros gastos
office or the hospital.
necesarios para trasladarse desde y hasta el consultorio
de su médico u hospital.
To help you keep a record of such expenses we have
Le proporcionamos este formulario para ayudarlo a
provided this form. In order to help insure that you are
llevar un registro de esos gastos. Con el objetivo de
properly reimbursed, list each item of expense below--
garantizar
que
usted
reciba
el
reembolso
whether or not you obtained a receipt (wherever
correspondiente, enumere cada ítem de gasto a
possible obtain receipts). Submit the completed form
continuación, tenga o no un recibo por ese gasto
and copies of all receipts or bills to the workers'
(siempre que sea posible, intente obtener un recibo).
compensation
insurance
carrier
(or
to
your
Envíe el formulario completo y copias de todos los
employer, if self-insured) and to the Workers'
recibos o facturas a la compañía de seguros de
Compensation Board.
(See Board address on
compensación para trabajadores (o a su empleador en
reverse.) It is suggested that you retain a copy of the
caso de que tenga un seguro propio) y a la Junta de
receipts and bills for your records.
Compensación
para
Trabajadores
(Workers'
Le sugerimos que guarde una
Compensation Board
copia de los recibos y facturas para sus registros.
NATURE OF EXPENSE / TIPO DE GASTOS
DATE / FECHA
AMOUNT / CANTIDAD
Continue on Reverse.
-
Sigue al dorso.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-257 (9-10)
LA JUNTA DE COMPENSACIÓN OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR.
NATURE OF EXPENSE / TIPO DE GASTOS
DATE / FECHA
AMOUNT / CANTIDAD
NYS Workers' Compensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY 13902-5205
Statewide Fax Line: 877-533-0337
Address for Email Filing: wcbclaimsfiling@wcb.ny.gov
C-257 (9-10) Reverse
www.wcb.ny.gov
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