Health Care Travel Expense (2721A) – WSIB in Ontario

The Health Care Travel Expense Form (2721A) form is designed for the submission of travel expenses related to medical and work transition appointments resulting from a workplace injury or illness. The form ensures that individuals can claim reimbursement for various travel-related costs incurred during their treatment or return-to-work process.

Follow these steps to accurately complete the Health Care Travel Expense Form (2721A):

General Guidelines

• Pre-Approval: Ensure that your travel expenses for medical and work transition appointments are pre-approved by WSIB to avoid payment delays.
• Documentation: Gather all necessary receipts and documentation related to your travel expenses before starting the form.
• Form Submission: Submit the completed form along with supporting documents at wsib.ca/submit.

Section A: Personal Information

• Claim Number: Enter your WSIB claim number.
• Name and Address: Fill in your last name, first name, and initial. Provide your current address, city, province, and postal code.
  • Check the box if this is a new address.
• Contact Information: Provide your home and work telephone numbers.

Section B: Travel Expense

Travel Details

1. • Date and Time: Enter the date (dd/mmm/yyyy) and time (a.m./p.m.) of your travel.
   • From and To: Specify the start and end locations of your travel.
   • Reason: Indicate the reason for your travel (e.g., medical appointment, return to work/school).

Type of Travel

1. • Check the appropriate box for the type of travel (Medical or Return to work/School).

Public Transit or Taxi

1. • If using public transit or a taxi, enter the amount spent and attach the original receipt.
   • Indicate whether the taxi receipt is enclosed by checking the appropriate box.

Driving Expenses

1. • Roundtrip Distance: Enter the total kilometers traveled.
   • Parking Cost: Record the amount spent on parking and attach the original receipt.
   • Indicate whether the parking receipt is enclosed by checking the appropriate box.

Escort

1. • Check ‘Yes’ or ‘No’ to indicate if an escort was required.
   • Enter the total amounts for meals (B – Breakfast, L – Lunch, D – Dinner) for both the claimant and escort.

Additional Entries

1. • If you have multiple travel dates and expenses, repeat the above steps for each entry.

Section C: Declaration

Signature and Date

1. • Sign and date the form to declare that all the provided information is true.
   • If submitting the form electronically, check the box to represent your signature and fill out your name and the date.

Mileage Rates

• Refer to the mileage rates provided in the form to calculate your driving expenses accurately.

Submission Checklist

Before submitting your form, ensure that you:

• Have your name and claim number on each form and receipt.
• Provide all requested information.
• Calculate the amounts you are claiming.
• Attach all original receipts for parking and taxi fares, if applicable.
• Sign and date the form.

Record Keeping

• Keep a copy of the completed form and all receipts for your records. This helps track your expense claims and prevents duplicate claims.

Contact Information

• For more information or if you require this form in an alternative format, contact WSIB at accessibility@wsib.on.ca or visit wsib.ca.

By following these instructions, you can accurately complete and submit the Health Care Travel Expense Form (2721A) to claim your travel-related expenses.