Medical Travel Refund Request Form - Guidelines
This form is required for requesting reimbursement of medically related travel expenses. It is used by individuals under the Federal Employees' Compensation Act, Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program. Ensure all fields are filled accurately to avoid delays in reimbursement.
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How do I fill this out?
To fill out this form, begin by entering the claimant's full name and case number. Next, provide the necessary travel details, including dates and locations. Lastly, ensure all sections are completed and sign the form before submission.
How to fill out the Medical Travel Refund Request Form - Guidelines?
1
Enter the claimant's full name and case number.
2
Provide travel details, including dates and medical facility information.
3
List all expenses and the total costs seeking reimbursement.
4
Include any required physician's signatures.
5
Sign and date the form before submission.
Who needs the Medical Travel Refund Request Form - Guidelines?
1
Federal Employees who need reimbursement for travel due to work-related medical appointments.
2
Individuals covered under the Black Lung Benefits Act requiring travel cost recovery.
3
Energy Employees who seek funds for illnesses related to their work.
4
Family members or payees of claimants who handle submissions on their behalf.
5
Healthcare providers who need to verify treatment for reimbursable travel expenses.
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What are the instructions for submitting this form?
To submit the completed Medical Travel Refund Request Form, send the form to the appropriate address based on your program. For FECA submissions, mail to OWCP/DFELHWC-FECA, PO Box 8300, London, KY 40742-8300. For Black Lung claims, send to DCMWC, Federal Black Lung Program, PO Box 8302, London, KY 40742-8302. Ensure that all original receipts are included, and for any questions regarding submission, contact the toll-free number provided in the instructions.
What are the important dates for this form in 2024 and 2025?
The OMB No. 1240-0037 for this form expires on June 30, 2024. Claims for the 2025 fiscal year will follow similar submission guidelines. Remember to regularly check for any updates to the requirements or dates after this expiration.
What is the purpose of this form?
The purpose of the Medical Travel Refund Request form is to allow eligible individuals to seek reimbursement for travel expenses incurred while attending medical appointments related to work-related injuries or illnesses. It serves those covered under federal programs, including the Federal Employees' Compensation Act and the Black Lung Benefits Act. By submitting this form, claimants can recover costs associated with necessary travel for medical care.
Tell me about this form and its components and fields line-by-line.
- 1. Claimant's Name: Full name of the person requesting reimbursement.
- 2. Case/Claim Number: Unique identifier for the claim.
- 3. Payee's Name: Name of the person receiving the reimbursement.
- 4. Address: Mailing address of the claimant or payee.
- 5. Date of Travel: Dates when the travel occurred.
- 6. Travel Details: Information about the locations and facilities involved in the travel.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in reimbursement for medical travel expenses. If not submitted correctly, claims may be denied, and the claimant will need to address any discrepancies.
- Delayed Reimbursement: If the form is not submitted, reimbursement claims will take longer to process.
- Denial of Claims: Incomplete or missing information can lead to denials of submitted claims.
- Additional Documentation Needed: Untimely submissions may require resubmissions or more documentation.
How do I know when to use this form?
- 1. Medical Appointments: When attending medically necessary appointments.
- 2. Reimbursable Travel: To seek reimbursement for travel related to healthcare services.
- 3. Federal Case Claims: For individuals under federal worker compensation programs.
Frequently Asked Questions
How do I fill out the Medical Travel Refund Request form?
Start by entering your personal information and travel details before providing expense summaries.
What types of expenses can be reimbursed?
You can request reimbursement for transportation, lodging, and meal expenses related to medical travel.
Is a physician's signature required?
Yes, a physician's signature is necessary for verification of services rendered related to the claim.
Can I edit the PDF form?
Absolutely, PrintFriendly offers built-in tools to edit and customize the PDF form before saving.
What if I forget to sign the form?
Missing signatures may delay processing; please ensure you sign before submission.
How do I submit the completed form?
Submit the form by mailing it to the appropriate OWCP address listed in the instructions.
Can I share the filled form with others?
Yes, PrintFriendly allows for easy sharing once you've completed and edited your PDF.
What if my claim is denied?
You can appeal the decision by following the outlined appeal process provided by OWCP.
How do I keep a copy of my filled form?
After editing, make sure to download and save a copy of the form for your records.
Who can help me if I have questions?
You can contact your OWCP claims examiner for assistance with any questions regarding the form.
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