California Medical Mileage Expense Form 2026
Choose the correct DWC form for the travel date, prepare the trip log, check the rate and totals, and preserve a complete reimbursement record.
This page is an independent walkthrough. Download the current English/Spanish medical mileage expense form directly from California DWC and follow the claim administrator’s delivery instructions.
Which 2026 mileage form should you use?
DWC lists two 2026 forms because the rate changed at midyear. Select the form by the date of each eligible trip, not the injury date or the date you submit the request.
| Travel date | DWC form version | Rate shown |
|---|---|---|
| July 1, 2026 or later | For travel on or after 7/1/26 | 76¢ per mile |
| January 1–June 30, 2026 | For travel on or after 1/1/26 | 72.5¢ per mile |
| Before January 1, 2026 | Historical form matching the travel period | Rate listed for that period |
When a log crosses July 1, split the entries between the two matching rate periods. DWC’s form directory provides historical versions back through 2017 and instructs users to contact Information and Assistance for an unlisted year.
Information to gather before completing the form
- Worker name and current contact information
- Employer and workers’ compensation claim details
- Claims administrator information from correspondence
- Date of every treatment or medical-legal trip
- Facility, provider, pharmacy, or evaluation destination
- Purpose of each trip and total eligible miles
- Parking and bridge-toll receipts
Complete the trip log carefully
- Enter one trip on each line. Use the actual travel date and identify the destination and medical purpose.
- Confirm whether miles are round trip. Do not double mileage that already includes the return journey.
- Use the rate printed for the form period. A July rate should not be applied to a June trip.
- Calculate the mileage subtotal. Multiply eligible miles by the applicable per-mile rate and check the cents.
- List supported additional expenses. Keep parking and bridge-toll amounts separate and attach receipts when available.
- Review, sign, and date. Make sure the identifying and claim information matches existing correspondence.
Our calculator can check a group of identical trips and add entered parking and bridge tolls, but the official form remains the reimbursement document.
Create a submission record
Before sending the form, save or print a complete copy with attachments. Record the recipient, delivery method, and date sent. If the claims administrator provides a mailing address, portal, fax, email, or other instruction, use the channel specified for the claim and preserve delivery confirmation where available.
Copy
Keep the signed form and every page of the trip log.
Support
Retain appointment evidence and parking or bridge-toll receipts.
Delivery
Keep proof showing when and where the package was sent.
If payment differs from the request, compare the paid mileage, applied rate, excluded trips, and additional expenses against your copy. Ask for the reason for any adjustment and use DWC Information and Assistance when general procedural help is needed.
Common form mistakes to avoid
- Using the injury date instead of the travel date to select a rate
- Putting June and July 2026 travel under one rate
- Submitting only a grand total without trip-level details
- Double-counting a return trip already included in round-trip miles
- Adding parking or bridge tolls without preserving receipts
- Leaving claim or contact information inconsistent with correspondence
- Sending the only copy of the log and attachments
Frequently asked questions
Is the DWC mileage form available in Spanish?
Yes. DWC’s medical mileage form directory labels the forms English/Spanish.
Can I reuse an old saved form?
Check DWC’s current directory first. DWC periodically revises forms, and the correct mileage form depends on the travel period.
Where do I send the form?
Use the recipient and delivery instructions provided for the claim, commonly the claims administrator. This independent page cannot identify the correct address for an individual claim.
Do I send medical records with every request?
Do not send unnecessary sensitive material. Preserve enough appointment or trip evidence to support the request and follow any applicable claim instructions.
Can StatutoryComp submit the form for me?
No. StatutoryComp does not collect claim information, contact insurers, or submit reimbursement requests.
What if I need a form for an older unlisted year?
DWC directs users to contact the Information and Assistance Unit at the closest WCAB district office when the needed year is not listed.
Official sources
- DWC medical mileage expense form directory — English/Spanish forms organized by travel period.
- DWC fillable-form instructions — official guidance for downloading, completing, saving, and printing forms.
- DWC workers’ compensation benefits — mileage, parking, bridge tolls, and travel-rate table.
- DWC Information and Assistance Unit — help resources for workers and other claim participants.
Page last reviewed: August 25, 2026. Always verify the current DWC form before sending personal or claim information.