State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES
AND REQUEST FOR REIMBURSEMENT
WCB CASE NO. SOCIAL SECURITY NO.CLAIMANT'S NAME
In connection with the above workers compensation case, you are entitled to be reimbursed for (1) medications or
supplies properly prescribed by your health care provider that you paid for yourself and for (2) fares, automobile
mileage or other necessary expenses going to and from your health care provider's office or the hospital.
To help you keep a record of such expenses we have provided this form. In order to help insure that you are properly
reimbursed, list each item of expense below -- whether or not you obtained a receipt (wherever possible obtain
receipts). Submit the completed form and copies of all receipts or bills to the workers' compensation
insurance carrier (or to your employer, if self-insured) and to the Workers' Compensation Board. (See Board
address on reverse.) It is suggested that you retain a copy of the receipts and bills for your records.
AMOUNTDATE
NATURE OF EXPENSE
C-257 (11-21)
Continue on Reverse.
RESIDENTIAL ADDRESS MAILING ADDRESS (IF DIFFERENT)
