WORKSAFE VICTORIA
WORKER REIMBURSEMENT REQUEST
Please use this form when requesting reimbursement of your claim related expenses
January 2017
Your Name Claim Number
This reimbursement request includes: (tick one or both as relevant)
o Medical expenses (securely attach invoices/receipts)
o Travel expenses (complete the table below & securely attach supporting documents)
For Travel Related Expenses: (additional space is provided on page 2 if required)
Date
Provider’s Name
(Treating
Practitioner)
Address
Method
of travel
(car, public
transport,
taxi
)
Zones
travelled
(public transport)
&/or
Km travelled /
parking / tolls
(private vehicle)
Cost
1
From To
Dr Smith 123 High St
Brunswick
385 Bourke St
Melbourne
Car 6km $1. 80
Further Information about Travel Reimbursements
1. Reimbursement is for reasonable travel expenses incurred by a worker to attend medical and hospital services required as a result of
an accepted work-related injury or illness, including reasonable costs associated with:
• private motor vehicle ($0.30 per km), including road tolls (on receipt of supporting documentation) and car parking (up to $15
of parking costs can be reimbursed without a receipt)
• public transport (up to the daily fare for zones or V/Line trip travelled)
• in some cases, the taxi travel to and from your treatment
2. Requests for travel expense reimbursements are required to be submitted within 6 months of date of travel
3. If your claim has not been accepted, reimbursement can only be made for travel to and from Medical assessments arranged by your Agent
For more information about WorkSafe’s Travel Expenses policy, please go to worksafe.vic.gov.au/policies
and click on Travel Expenses for Medical and Hospital Services Policy.
Worker Declaration
I declare that the details I have given on this form are true and correct and relate to travel required to attend medical and/or hospital services
required for my accepted work-related injury or illness. I understand that it is an offence to provide false or misleading information.
Your Signature Date
Print name
Please return your completed form and any attachments to the Agent managing your claims (by mail or email)
If you have any queries regarding these expenses, please contact your Agent
FOR890/01/12.16
E.g.:
01/07/16
