Fill and Sign the Request to Get Reimbursed for Travel Costs Form

DWC048 DWC048 Rev. 02/17 Page 1 of 2 Request to Get Reimbursed for Travel Costs Este formulario está disponible en español en el sitio web de la División en http://www.tdi.texas.gov/forms/dwc/dwc048trvlreims.pdf . Para obtener asistencia en español, llame a la División al 800-252 -7031. Injured Employee : Fill out Sections A-C and send it to the insurance carrier . If you need a fax number for the insurance carrier, call us at (800) 252 -7031. See page 2 for details . A . Information about Injured Employee, Employer, and Insurance Carrier 1. Employee Name (First, Middle , Last) 2. Date of Injury (mm/dd/yyyy) 3. Employee Mailing Address (Street or PO Box, City, State, ZIP Code) 4. Employer (at time of injury) 5. Employee Phone Number 6. Insurance Carrier Name 7. Insurance Carrier Fax # B . Information about Travel 8. T rips for medical treatment and exams more than 30 miles one way . Date Travel From (street address) Travel To (health care provider’s name and street address) Miles Driven (round trip) To estimate amount: total miles X state mileage rate = amount reimbursed Go to https://fmx.cpa.state.tx.us/fm/travel/travelrates.php for the state mileage rate or call us at (800) 252 -7031 . 9. Overnight stay s and meals. Send receipts for these costs . Date Location Meals* Hotel/Lodging* $ $ $ $ $ $ $ $ * The amount reimbursed cannot be more than the rates for state employees . To get those rates, go to https://fmx.cpa.state.tx.us/fm/travel/travelrates.php or call us at (800) 252-7031 . C . Injured Employee ’s Statement I certify the above information is correct and is for travel for treatment or an exam for my work -related injury. 10. Sign here : 11 . Date: Complete if known: DWC Claim # Carrier Claim # DWC048 DWC048 Rev. 02/17 Page 2 of 2 Insurance Carrier : You must provide a plain language explanation of any partial payment or denial under 28 T exas A dministrative Code (TAC) §134.110(f). You may complete Section D or use your own form and send a copy to the injured employee and the injured employee’s representative, if any . D . Insurance Carrier ’s Response to Injured Employee’s Request to Get Reimbursed for Travel Costs Injured Employee: If your request was denied or partially denied, you may appeal by asking for a benefit review conference. Call (800) 252 -7031 or go to www.tdi.texas.gov/forms/dwc/dwc045brc.pdf to complete DWC Form -045 . Things to Know If you have a work-related injury, you can get reimbursed for travel costs for some medical treatment s or exam s more than 30 miles one way if : • Medical treatment is not reasonably available within 30 miles of where you live; or • Required medical exam s, designated doctor exams , and post -designated doctor treating or referral exams are more than 30 miles one way . Mileage: If you travel from your home or work place to the health care provider’s office, y ou can get reimbursed for mileage using the shortest reasonable route. Some things to know: • If you left from a place other than your home or work place , mileage will be based on the distance from the health care provider’s office to your home , work place, or actual point of departure, whichever is close st. • The amount reimbursed will be based on the travel rate for state employees . To get those rates, go to https://fmx.cpa.state.tx.us/fm/travel/travelrates.php or call us at (800) 252-7031 . Hotel and meals: If your travel reasonably includes an overnight stay, you can get reimbursed for the cost of a hotel or other lodging and meals related to your trip. Some things to know: • You must send a copy of receipts for an overnight stay and your meals with this form. • The amount reimbursed cannot be more than the rates for state employees . Those rates are posted at https://fmx.cpa.state.tx.us/fm/travel/travelrates.php or call us at (800) 252 -7031 . How to file this form: Complete and sign the form . Send it to the insurance carrier within 1 year of when you incurred (charged) these costs. Keep a copy of the completed form and receipts. If you need help, call us at (800) 252 -7031 . What happens next: W ithin 45 days of getting your form , the insurance carrier must reimburse you r request for travel costs or deny your request by completing Section D or using its own form explaining why it won’t pay for the travel. Y ou can ask for a benefit review conference if the insurance carrier won’t reimburse all or part of your travel costs . At the c onference, someone from the Division of W orkers’ Compensation will listen to you and the insurance carrier and try to help you reach an agreement. An injured employee who is not represented by an attorney may also receive assistance by contacting the Office of Injured Employee Counsel at (866) 393 -6432. M ore information : See 28 TAC §134.110 about reimbursement of travel expenses; Labor Code §408.004(c)(2) and 28 TAC §126.6(l) about required medical exams; Labor Code §408.0041(h)(2) and 28 TAC §126.17(c) about post -designated doctor treating or referral doctor exams. NOTE : With few exceptions, upon your request, you are entitled to be informed about the information T DI-DWC collects a bout you; get and review the information (Government Code, §§552.021 and 552.023); and have TDI -DWC correct information that is incorrect (Government Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov . 12 . Response Requested amount is: Approved Denied Partially Denied 13. Reason 14 . Adjuster Name: 15. License Number: 16. Date: