Claim Reimbursement Form (2024)

Virginia Birth-Related Neurological Injury Compensation Program

Claim Reimbursement Form

Admitted Claimant (First and Last Name)

Month/Year

Example: January 2025

Select Vehicle Type*

CarVanI did not drive in a car for the reimbursement.

	Date	Description/Provider/Services/Items	Mileage	Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Total Miles

Car Mileage Miles x Rate (Based on personal car at $0.67)

Van Miles x Rate (Based on Program van at $0.335)

Subtotal

Total Reimbursement (Car)

Total Reimbursement (Van)

Print Name*

Email*

example@example.com

Upload Your Documentation Here

Example: PDF, Word, or JPG (screenshots) documents up to 25 attachments

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*

Type your name blanks

Additional explanation: