MILEAGE REIMBURSEMENT




NAME: 

ADDRESS: 

ZIP:

SOCIAL SECURITY # :  ( Required)

Submit your mileage for all trips that exceed 5 miles round trip, if the purpose of the trip was to obtain medical care or purchase medically related items, such as prescriptions. Please submit
this mileage request on a monthly basis until your file is closed.

DATE: 
MILES: 
DESTINATION:

DATE: 
MILES: 
DESTINATION:

DATE: 
MILES: 
DESTINATION:

DATE: 
MILES: 
DESTINATION:

DATE: 
MILES: 
DESTINATION:

DATE: 
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DESTINATION:


MAIL TO: State Self Insurance Fund 900 SW Jackson, Room 920-N
Landon State Office Building Topeka, KS 66612-1251