Mileage Reimbursement Form for Workers’ Compensation Covered Claims

The employer should provide a mileage reimbursement form to an employee who has a covered workers’ compensation claim for a work-related injury or illness. The employee uses the form to record mileage to receive reasonable and necessary medical treatment for the covered work-related injury or illness. The mileage is then reimbursed to the employee as part of the workers’ compensation benefit.

The injured employee submits the form to the assigned MCIT workers’ compensation claim representative.