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The document captures essential employee details, including contact information, injury claim number, and date of injury, alongside a structured log for recording visit dates, medical facility names, purposes of visits, and total round-trip mileage. By signing this form, the employee certifies the accuracy of the reported information and acknowledges the legal consequences regarding potential fraud under Georgia state law. This document serves as a critical financial instrument for administrative compliance within the State of Georgia, ensuring that all mileage reimbursement claims are handled with full transparency, accountability, and adherence to the statutory regulations governing workers' compensation processes within the jurisdiction.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/workers-compensation-mileage-reimbursement-request/307245/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/workers-compensation-mileage-reimbursement-request/307245.png","ImageObject",442,249,{"name":88,"@type":89},"McQueen","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to process a mileage reimbursement request?","Question",{"text":108,"@type":109},"Employees must provide their name, address, claim number, date of injury, and a detailed log of medical visits including the date, provider name, visit purpose, and round-trip mileage.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is the legal implication of providing incorrect information on this form?",{"text":113,"@type":109},"Any misrepresentation of mileage is considered fraud under the Georgia Workers' Compensation Statute, which may lead to legal fines or imprisonment.",{"name":115,"@type":106,"acceptedAnswer":116},"Who is the issuing authority for this reimbursement form?",{"text":117,"@type":109},"The form is issued by the State of Georgia Department of Administrative Services for use in workers' compensation claims.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307245,1790913605,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},5909890329169,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Workers’ Compensation Mileage Reimbursement Request  \n\n| EMPLOYEE |  |\n| --- | --- |\n| EMPLOYEE ADDRESS |  |\n| CLAIM \\# |  |\n| DATE OF INJURY |  |\n\n\n| Date of Visit | Name of Doctor of Facility | Purpose\u003Cbr>of\u003Cbr>Visit | Round\u003Cbr>Trip\u003Cbr>Mileage |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nMy signature on this form indicates a true representation of mileage and medical trips. I understand any misrepresentation on mileage will be considered Fraud under the Ga Workers' Compensation Statute and subject me to possible fines and imprisonment under Georgia Statute.  \n\n| Signature | Date: |\n| --- | --- |","cbCaip7BnpCnObZU","https://ap.wps.com/l/cbCaip7BnpCnObZU","pdf",229135,"English","# Employee Information\n## Mileage and Medical Visit Log\n## Certification and Signature","[{\"question\":\"What information is required to process a mileage reimbursement request?\",\"answer\":\"Employees must provide their name, address, claim number, date of injury, and a detailed log of medical visits including the date, provider name, visit purpose, and round-trip mileage.\"},{\"question\":\"What is the legal implication of providing incorrect information on this form?\",\"answer\":\"Any misrepresentation of mileage is considered fraud under the Georgia Workers' Compensation Statute, which may lead to legal fines or imprisonment.\"},{\"question\":\"Who is the issuing authority for this reimbursement form?\",\"answer\":\"The form is issued by the State of Georgia Department of Administrative Services for use in workers' compensation claims.\"}]","Workers- Compensation Mileage Reimbursement Request | PDF",1789846240]