California Medical Mileage Expense Form 2026
Complete each field on the official DWC form, attach receipts, send the original to the insurance company, and keep the full reimbursement record.
This page is an independent line-by-line walkthrough. Download the current English/Spanish medical mileage expense form directly from California DWC; use the reimbursement guide for the broader eligibility and submission rules.
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.
Send the form to the correct recipient
The current DWC form says to attach receipts, send the original to the insurance company, and keep a copy. It also says not to send the original or a copy to the local Workers’ Compensation Appeals Board or an Information and Assistance officer.
Original
Send the signed form and supporting receipts to the insurance company handling the claim.
Copy
Keep the entire package and preserve delivery confirmation when available.
60-day follow-up
If payment has not arrived within 60 days, contact a DWC Information and Assistance officer.
If payment differs from the request, compare the paid mileage, applied rate, excluded trips, and additional expenses against your retained copy before seeking procedural help.
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?
The current DWC form says to send the original to the insurance company and keep a copy. Use the insurer’s current address or approved delivery channel from the claim correspondence; do not send the form to the local WCAB or an I&A officer.
Do I send medical records with every request?
Do not send unnecessary sensitive material. Attach the receipts directed by the form and preserve enough appointment or trip evidence to support the request.
Can StatutoryComp submit the form for me?
No. StatutoryComp does not collect claim information, contact insurers, or submit reimbursement requests.
What if payment has not arrived after 60 days?
The current form directs the worker to contact a DWC Information and Assistance officer.
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 form for travel on or after July 1, 2026 — 76-cent rate, required fields, receipts, delivery, and follow-up instructions.
- DWC form for travel beginning January 1, 2026 — 72.5-cent rate and the same filing sequence.
- 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: October 6, 2026. Always verify the current DWC form before sending personal or claim information.