When submitting a claim for medical travel expenses you must submit the following information for your claim to be considered for reimbursement:
- Receipt for your services. This is the receipt for your healthcare expense and should include the details of the products or services received. You can use an itemized receipt from your provider or an Explanation of Benefits from your health insurance company.
- Mileage Worksheet
- Signed certification and authorization statement. This is a letter from a physician providing the reason why travel for products or services are required
A Mileage Worksheet submitted without a signed and dated certification and authorization statement will not be considered for reimbursement.
Please include the following information with your mileage claim:
- Date of service
- Type of service (e.g., doctor visit, a trip to the pharmacy)
- Actual mileage and rate (e.g., 16 miles round trip at $0.21/mile)
- Total amount requested (e.g., 16 x 0.21 = $3.36)
It is also recommended that you submit a screenshot of Google Maps to clarify the route from your residence to the health care facility.