Printable Owcp Mileage Reimbursement Form This is a mileage only reimbursement form If you need other travel expenses reimbursed complete Form OWCP 957 Part B Medical Travel Refund Request Expenses Enter claimant s full name last name first name middle initial M I Enter claimant s claim case file number
This form should be used for medically related travel covered by the Federal Employees Compensation Act the Black Lung Benefits Act and the Energy Employees Occupational Illness Compensation Program Act of 2000 1 Claimant s Name Last First Mi OMB No 1215 0054 Expires 08 31 2010 2 This form is to be used to seek reimbursement for out of pocket medical expenses pertaining to the treatment of an accepted condition Form OWCP 915 can be used to seek reimbursement for expenses in regard to medical treatment prescription medication and medical supplies
Printable Owcp Mileage Reimbursement Form
Printable Owcp Mileage Reimbursement Form
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Call us at 800 718 5658 How to get reimbursed for travel Traveling to doctors appointments testing appointments and picking up medication can get expensive quickly Luckily EEOICPA white card holders can get reimbursed for any mileage related to medical travel by filling out an OWCP 957 Form General Administrative Forms References Note For program specific forms please click the respective program link above Claimant Reimbursement Claimant Medical Reimbursement OWCP 915 Medical Travel Refund Request OWCP 957 Provider Enrollment Application OWCP 1168
DFEC Travel Authorization Request Fax 1 800 215 4901 Please read the instructions carefully before completing authorization request Complete all applicable fields All Prior Authorization requests must either be faxed on this template or be submitted through the Web Bill Processing Portal https owcpmed dol gov Fax with supporting Do not upload Medical or Travel reimbursement forms OWCP 915 OWCP 957 Doing so will unnecessarily delay the processing of your reimbursement claim Medical or Travel reimbursement forms must be mailed to OWCP DFELHWC FECA P O Box 8300 London KY 40742 8300 UPLOAD DOCUMENTS
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This is a mileage only reimbursement form If you need other travel expenses reimbursed complete Form OWCP 957 Part B Medical Travel Refund Request Expenses 1 Enter claimant s full name last name first name middle initial M I 2 Enter claimant s claim case file number 3 Under the FECA the Office of Workers Compensation Programs OWCP authorizes medical services appliances or supplies likely to cure give relief reduce the degree or period of disability or aid in lessening the amount of the monthly compensation 5 USC 8103
To request mileage reimbursement the injured federal employee must complete a Form OWCP 957 which is available on the OWCP website or from their employing agency s workers compensation coordinator The form requires the employee to provide information about their injury or illness the medical provider they are seeing and the dates and What is the mailing address for claim reimbursements Please submit your claims for reimbursement to the applicable address below Division of Federal Employees Compensation DFEC PO Box 8300 London KY 40742 8300 Division of Energy Employees Occupational Illness Compensation DEEOIC PO Box 8304 London KY 40742 8304
Fillable Mileage Reimbursement Form IRS Mileage Rate 2021
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This is a mileage only reimbursement form If you need other travel expenses reimbursed complete Form OWCP 957 Part B Medical Travel Refund Request Expenses Enter claimant s full name last name first name middle initial M I Enter claimant s claim case file number
https://saaal0195-apwu.org/wp-content/uploads/2018/05/OWCP-957-Mileage-Reimbursement.pdf
This form should be used for medically related travel covered by the Federal Employees Compensation Act the Black Lung Benefits Act and the Energy Employees Occupational Illness Compensation Program Act of 2000 1 Claimant s Name Last First Mi OMB No 1215 0054 Expires 08 31 2010 2
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Printable Owcp Mileage Reimbursement Form - General Administrative Forms References Note For program specific forms please click the respective program link above Claimant Reimbursement Claimant Medical Reimbursement OWCP 915 Medical Travel Refund Request OWCP 957 Provider Enrollment Application OWCP 1168
