Virginia Birth-Related Neurological Injury Compensation Program
Claim Reimbursement Form
Admitted Claimant (First and Last Name)
Month/Year
Example: January 2025
Select Vehicle Type
*
Car
Van
Date
Description/Provider/Services/Items
Mileage
Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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20
Total Miles
Car Mileage Miles x Rate (Based on personal car at $0.70)
Van Miles x Rate (Based on Program van at $0.335)
Subtotal
Total Reimbursement (Car)
Total Reimbursement (Van)
Print Name
*
Email
*
example@example.com
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*
I certify the information given is accurate, that none of these items items have been reimbursed by any other source for any amount, nor are they eligible for reimbursement from other sources.
Signature Date
*
Additional explanation:
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