Patients

Medical mileage reimbursement.

Name: North County Orthopedic Medical Group
Address: 8929 University Center Ln, Ste 100, San Diego, CA, 92122, US
Telephone: (858) 457-4040
Price range: $$

Track your Workers' Comp travel, generate a completed PDF, and submit it to your adjuster.

Call (858) 457-4040 All forms

Medical Mileage Reimbursement

Current mileage rate: $0.70/mile (1970).

If you travel to get treatment for your work injury, you're entitled to repayment of travel costs at $0.70/mile. Reasonable travel to the pharmacy, plus parking, tolls, and public transportation, is also included. Complete this form and attach receipts. Send the original to the insurance company and keep a copy — do NOT send it to the WCAB or the I&A officer. If your costs aren't paid within 60 days, contact the I&A officer.

Download blank official DWC form (PDF)

Injured worker's name *

Claim number

Trips

Trip 1

Date *

Round-trip mileage *

Parking ($)

Tolls ($)

Traveled from (address) *

Traveled to (name + address of doctor / hospital / therapist) *

Totals

Total miles × $0.70

Mileage reimbursement

0.0 mi

$0.00

Total parking

$0.00

Total tolls

$0.00

TOTAL REIMBURSEMENT REQUESTED$0.00

Receipts (parking / tolls / transit)

Attach photos or PDFs of any receipts.

Receipts (parking / tolls / transit) #1

JPG, PNG, HEIC, or PDF — up to 10 MB

Fraud statement

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Cualquier persona que a sabiendas presente reclamos falsos o fraudulentos para el pago de una pérdida, será culpable de un delito y se le podría multar y encarcelar en la penitenciaría estatal.

Signature

Printed name *

Draw your signature *

Sign with finger, stylus, or mouse

Date: 9/10/2026

I agree to receive emails from North County Orthopedic Medical Group about my request (confirmations and follow-up).I agree to receive text messages from North County Orthopedic Medical Group about my request. Msg & data rates may apply. Reply STOP to opt out.

Do not include sensitive medical information beyond what's asked. For medical emergencies, call 911. No information is stored on your device. Submissions are transmitted securely to our intake system.

Se habla español · Workers' Comp & Longshore accepted · Most major insurance plans