Fill and Sign the Workers Compensation Request for Reimbursement of Expenses Oregon Form

Request for Reimbursement of Expenses Complete this form, including your workers’ compensation claim number, and send it to the insurer that processes your claim. Include copies of receipts for all items except private vehicle mileage. Incomplete requests will be returned for additional information. You must request reimbursement within two years from date of service.             Name Claim number       Mailing address Apt. # This is a new address                (     )     -      City State ZIP Phone                      P.O. Box City State ZIP TRANSPORTATION Start location End location Medical provider Trip miles Date                                                                                                                                                                                           TOTAL miles MEALS DateBreakfast City Date Lunch City Date Dinner City       $                   $                   $                   $                   $                   $                   $                   $                   $             $       TOTAL meals reimbursement LODGING Hotel/motel name Location Date Cost                   $                         $                         $       $       TOTAL lodging reimbursement PRESCRIPTIONS Name of medication Doctor Date Cost                   $                         $                         $                         $       $       TOTAL prescription reimbursement By my signature, I certify that all information I have given in this request for reimbursement is true and contains no false statements or misrepresentations.       TOTAL miles       $       Signature of worker Date TOTAL meals, lodging, and prescription reimbursement 440-3921 (10/18/DCBS/WCD/WEB) Standard rates for the continental United States: Lodging and meal rates effective Oct. 1, 2018 – Sept. 30, 2019 ALL private vehicle mileage effective Jan. 1, 2018 54.5 cents per mile Breakfast $13.75 Previous mileage rates: Lunch $13.75 01/01/17 – 53.5 cents per mile Dinner $27.50 01/01/16 – 54 cents per mile Lodging $94.00 01/01/15 – 57.5 cents per mile 01/01/14 – 56.0 cents per mile Lodging rates do not include taxes. Room taxes are reimbursable in addition to the lodging allowance. Lodging and meal rates exceed the standard rate in the following Oregon locations: County Effective dates Max. lodging rate* Meal rate ** Clackamas All year $116 $56 Clatsop 10/1 – 6/30 $110 $71 7/1 – 8/31 $182 $71 9/1 – 9/30 $110 $71 Deschutes 10/1 – 5/31 $113 $61 6/1 – 8/31 $158 $61 9/1 – 9/30 $113 $61 Lane All year $115 $61 Lincoln 10/1 – 6/30 $107 $66 7/1 – 8/31 $151 $66 9/1 – 9/30 $107 $66 Multnomah 10/1 – 10/31 $184 $66 11/1 –3/31 $150 $66 4/1 – 9/30 $184 $66 Washington All year $133 $61 *Lodging rates do not include taxes. Room taxes are reimbursable in addition to the lodging allowance. **For meals, the following percentages must be used: breakfast -- 25%; lunch -- 25%; dinner -- 50% Rates obtained from Bulletin 112. See bulletin for more information.