Risk Management

Workers' Compensation (CARO) Injured Employees' Resources

Mileage Reimbursement Guidelines and Form Directions

Pursuant to 287.140 RSMo., when an employee is required to submit to medical examination or necessary medical treatment at a place outside of the local or metropolitan area from the employees principal place of employment, the employee shall receive reasonable reimbursement.

The Mileage Reimbursement Request Form provides documentation of miles traveled to seek authorized medical care for a work-related injury.  This form can be submitted to CARO by the injured employee or state agency.

Form Directions

To be completed by employee:

Name and address of the employee
CARO case number (if known)
Date of Injury
Name of State Agency

The employee should indicate the dates traveled, the city they are departing from and what city they are traveling to seek medical care due to the injury. The employee should also indicate the number of round trip miles traveled. The form should be completed with the employee's signature.

To be completed by the medical provider:
To confirm mileage traveled, the employee should have the medical provider complete this portion of the form at the time the treatment is rendered. The medical provider should provide their name, address, and sign and date the form.

To be completed by CARO:
If mileage is determined to be due, this portion of the form is completed by CARO at the time payments is processed based upon the state mileage allowance rate in effect on the date the employee traveled to the medical provider.