Texas Medical Appointment Mileage Form

Keeping track of travel between medical appointments and your home is crucial towards establishing a strong case. Our Medical Appointment Mileage Form helps you keep track of mileage and can easily be sent to your assigned Case Manager.

NOTE: Only travel to and from treatment facilities associated with your accident and your home will be considered for reimbursement.

Mile Entry #1

Date:

Provider:

Miles: *

Description:

Add Appointment

Total

First Name: *

Last Name: *

Submit Your Miles

Date	Provider* (Medical Facility)	Miles *	Description of Appointment*

Add Appointment

Total

First Name: *

Last Name: *

Submit Your Miles