Claimant Name (or Auth Rep):
City, State, Zip
Dear Claimant Name (or Auth Rep):
This letter is in reference to your request for medical travel authorization under the Energy Employees Occupational Illness Compensation Program Act. You (or you and your companion) are authorized to travel for medical treatment with (Insert name of doctor or medical facility) in (City / State). Outlined below are the itemized travel allowances approved for your trip:
- Dates of Trip: (Insert authorized travel dates)
[Or in the alternative]
- Multiple Trips Authorized (Insert Authorized travel date range)
- Trip Origin & Destination: (Insert starting City/State and ending points)
- Authorized mode of travel (Insert approved mode: auto, air, etc.)
- Meals & Incidental Expenses (M&IE) See below.
- Lodging (single or double occupancy) See below.
- Airfare allowance See below.
- Mileage allowance for personal vehicle (Insert appropriate mileage rate or N/A)
- Companion approved to travel: (Insert name of companion or N/A]
- Rental car reimbursement Indicate “YES” or N/A]
Companion Travel: If you have been authorized a companion to accompany you on this trip, you will be reimbursed at twice the daily M&IE rate and lodging will be based upon double-occupancy, unless otherwise approved. If travel is by commercial airline, then the companion airfare will be reimbursed as well. The expenses for your companion will be paid to you, not to the companion, or any other party.
Travel Changes: We understand your travel may not happen as originally planned. If you encounter a change in your travel plans (such as an extended stay) that may result in additional expenses, please contact me or the DEEOIC Resource Center identified below at your earliest convenience to let us know the specific changes. We will be glad to assist you with any adjustments to your authorization so you won’t encounter any delays in your reimbursement.
How to File for Travel Reimbursement: Reimbursement requests must be submitted using the enclosed Form OWCP-957. Only travel costs that are directly related to obtaining medical treatment for your accepted condition(s) will be reimbursed. Receipts are required for all lodging, airfare, rental car (if authorized), and gasoline purchases (for approved rental car only). Any other expenses under $75.00 do not require receipts. The OWCP-957 form includes an
instruction sheet; however, I would like to provide you with some additional information to help you with your reimbursement request:
M&IE: Itemization of expenses and submission of receipts is not required for meals and incidental expenses (MIE). The MIE expenses are reimbursed as a fixed-rate, daily allowance, regardless of what you actually spend, and are determined by the Government Services Administration (GSA) published rate for the geographic location of your stay on any given day.
By GSA rule, reimbursement for the first and last days of travel is 75% of the daily fixed-rate for MIE.
Lodging: Daily lodging rates are also based on applicable GSA rates for the location of your stay and may change due to seasonal fluctuations so be sure to check the current rates. State and local lodging taxes are not included in the daily lodging rate and will be reimbursed separately. All receipts must be submitted.
Rental Car: When a rental car has been approved, reimbursement will be based upon an economy-sized vehicle, unless otherwise approved. Gasoline
purchases for the rental car are reimbursable. All receipts must be submitted.
Airfare: Airfare reimbursement will be based upon the actual cost incurred, but not to exceed the cost of a refundable coach or economy class fare (Y-Class airfare). All receipts must be submitted.
GSA Rates: The daily allowances for MIE and lodging are determined by GSA, for specific cities and geographic areas around the country, and they vary by region. These rates are revised occasionally by GSA. For more information on these GSA-published rates, please visit the GSA Website at: www.gsa.gov ; or contact your nearest resource center for assistance.
Where to Send Your Reimbursement Forms: Send a copy of this authorization letter, along with your itemized Form OWCP-957, along with any required receipts, to our bill processing agent. For your convenience, I have enclosed a pre-paid envelope and an extra copy of this authorization letter. Please send your information to:
(Insert Name and Address of the DEEOIC Bill Processing Agent)
Where to go for Help: For assistance in completing your travel reimbursement form, or in determining applicable MIE and lodging rates, or if you need other assistance related to this travel authorization or reimbursement process, please contact your nearest DEEOIC Resource Center, or call me. Below is the address of your nearest Resource Center.
Insert complete RC address
Additional information and forms are also available on our website at: https://www.dol.gov/owcp/energy/. Please have a safe trip and let me know if you have any other concerns that are not addressed in this letter. I can be reached, toll free, at: (Insert toll free number).
[Telephone and Fax Numbers]
Enc: OWCP-957 (2 blank forms)
Prepaid envelope addressed to bill processing agent
Copy of Authorization Letter (2 copies)