Free Form 25T - North Carolina

North Carolina Industrial Commission
IC File #

ITEMIZED STATEMENT OF CHARGES FOR TRAVEL
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File # Employer FEIN

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Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City City

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Telephone Number State Zip

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M
Sex

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State Zip

Home Telephone Social Security Number

Work Telephone

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Date of Birth

Carrier's Telephone Number

Fax Number

Employees are entitled to reimbursement of $0.55 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting January 1, 2009. (The mileage rate is $0.585 for July 1-December 31, 2008; $0.505 for January 1-June 30, 2008; $0.485 for 2007; $0.445 for January 18-December 31, 2006; and $0.31 for travel before that date.) Special consideration will be given to employees who are totally disabled. No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers (G.S. §97-25). DATE / / / / / / / / / / If overnight stay is necessary, the following items will be approved as submitted. (Receipts must be furnished for carrier's file.) Total motel expense ($45.00 per day): Total meal expense ($6.00 Breakfast, $8.00 Lunch, and $14.00 Dinner): Total parking & cab expense (actual charge): Total for other expenses: Total Miles:
X [mileage rate]*

NAME OF MEDICAL PROVIDER

CITY

TOTAL MILES ROUNDTRIP

OTHER EXPENSES

Other expenses: Total all expenses:

*The mileage rate is $0.55 for travel, starting January 1, 2009; $0.585 for travel from July 1 to December 31, 2008; $0.505 for travel from January 1 to June 30, 2008; $0.485 for travel in 2007; $0.445 for travel from January 18 to December 31, 2006; and $0.31 for travel before that date.

I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury.

Employee signature Employee: Mail your bill in duplicate promptly to employer and/or insurance carrier

Carrier's approval Employer or Carrier/Administrator: Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval. Pay and retain copy in carrier's file.

FORM 25T 01/09 PAGE 1 OF 1

FORM 25T

FOR ASSISTANCE, CALL: N.C. INDUSTRIAL COMMISSION MAIN TELEPHONE: (919) 807-2500 WORKERS' COMPENSATION INFORMATION SPECIALISTS: (800) 688-8349