420 Oak Street
Prakken 153
Big Rapids, MI 49307-2020
Phone: (231) 591-3848
Fax: (231) 591-2978
Web: www.ferris.edu
WorkersCompensation Mileage/Travel Reimbursement Form
Name_______________________________________
Address______________________________________________
_____________________
________________________________
PLEASE LIST EACH TRIP AS IT IS TAKEN, EACH ON A SEPARATE LINE.
SUBMIT MILEAGE FORMS AT LEAST EVERY 30 DAYS FOR REIMBURSEMENT.
DATE DOCTOR, HOSPITAL,
OR MEDICAL FACILITY
Address, City & Zip
(Will not be reimbursed without complete address)
ROUND
TRIP
MILES
For Provider Use Only
(doctor, therapist, etc.)
Please sign & date below
Please Sign________________________________________ Total Miles__________
Pl
ease Return Completed Form to:
Non-reimbursable items include:
Mileage to retail stores/pharmacies
Unverified mileage
Tolls & parking without receipts
Please use this format when requesting travel
expense reimbursement. Your cooperation will
help us process your reimbursement more
quickly. Remember, your provider must date
and sign each visit.
Pl
ease allow 30 days for processing of your
Travel Reimbursement request and a few extra
days for mailing.
Ferris State University
SHERM
420 Oak St., PRK 153
Big Rapids, MI 49307
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