WebIn connection with the above workers compensation case, you are entitled to be reimbursed for (1) medications or supplies properly prescribed by your health care provider that you paid for yourself and for (2) fares, automobile mileage or other necessary expenses going to and from your health care provider's office or the hospital. WebDivision of Workers' Compensation 7551 Metro Center Drive, suite 100, Austin, Texas 78744-1645 (800) 252-70311 I @TexasTDl DWC048 Complete if known. DWC Claim # Carrier Claim # Request to Get Reimbursed for Travel Costs Este formulario está disponible en español en el sitio web de la División en
Request to Get Reimbursed for Travel Costs
WebDownload Free Print-Only PDF OR Purchase Interactive PDF Version of this Form. Request For Travel Reimbursement Form. This is a Texas form and can be use in Employee … WebApr 2, 2024 · Medical Mileage Expense Form - English and Spanish (01-2008) Nontransferable Training Voucher Form. DWC-AD10133.57. Notice of Change or Rate in Payment Schedule. DWC-500F. Notice of Delay in Determining Liability - Instructions. Notice Of Delay In Determining Liabilty For Workers' Compensation Benefits. on my block ray
Medical Travel Refund Request U.S. Department of Labor - DOL
WebThe IE must submit a DWC Form-048, Request for Travel Reimbursement to the IC within one year of the date the expenses were incurred. 28 TAC Section 134.110 (b). The request must include documentation or evidence (such as itemized receipts) of the amount of the expense. 28 TAC Section 134.110 (c). WebDWC-48, Request for Travel Reimbursement: PDF: DWC-53, Employee's Request to Change Treating Doctor - Non Network: English: Spanish: DWC-73, Work Status Report: … http://www.wcb.ny.gov/content/main/Forms.jsp on my block quinceanera