Document dYnGnv6g5wnQ2nOo7BrkQBB86

STATEMENT OF EXPENSES FOR ATTENDANCE AT SPECIALIST EXAMINATION CLAIM NO. c'Jp f 3-2-T- CLAIMANT: m/////S? sri . EXAM DATE: ADDRESS: EXAM TIME: y os?/*/ /}/-//d _____________ _________________________ y Is this a new address? No Yes Travel Expenses: If the required travel is by automobile and the destination is greater than 50 miles round trip of the claimant's residence then reimbursement shall be at the rate of 22 cents per mile (all rates subject to change) portal to portal, using the most direct and practical route. Taxicab fares will be refunded only where the claimant's physical condition requires such transportation. Special transportation shall be pre-authorized. If claimant is traveling by railroad or bus, claimant shall be entitled to the actual and necessary railroad or bus fare. Hotels 4 Meals: The cost of necessary hotels will be paid at actual cost not to exceed $40.00 per night plus applicable taxes. Necessity for hotel accommodation must be pre-authorized. Necessary meals, based on distance traveled round trip, shall be refunded to the claimant, not to exceed the following schedule: 51 - 99 miles: $3-50 "100 - 150 miles: $7.50 over 150 miles: $12.50 MILEAGE SHOULD NOT EXCEED 200 MILES ONE HAY UNLESS PRIOR AUTHORIZATION HAS BEEN GIVEN BY THE INDUSTRIAL COMMISSION BUS/TRAIN/<$UT0M0BILEj> From: </, //&* to 4s/,97X. BUS/TRAIN^UT0M0BiTe> From: // to TOTAL MILES: /J O X $.22 PER MILE = $ MEALS: (BREAKFAST) $ X (LUNCH) $ Z ^ / (DINNER) $_^ TOTAL MEALS $ -M- , PLUS TOTAL TRAVEL $ J-f'. L O = $_____ If examination is conducted in a physician's office or hospital, enclosed form by mail to: INDUSTRIAL COMMISSION OF OHIO ,, 161 S. High Street, 3rd Floor Akron, Ohio 44308 (216) 379-3550 ^ fa 'tfc J ARE YOU PRESENTLY EMPLOYED? No t/ Yes EMPLOYER 4 ADDRESS The claimant certifies that the above statements are true and that all said sums for traveling expenses were used for the purpose mentioned. <~*rSIGNATURE OF CLAIMANT -and- (AREA CODE) TELEPHONE NUMBER /k CJy 1 V WWTITTNFE.SS NCRWP (QIC 2001 - MED2) Revised 1/89 stew** itfW**1 oe* GENG 002132 w