Adrianotosi_mileage Reimbursement Form
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Argonaut Claims Services.
Attention to: Donna Hall Mileage Reimbursement Form Date: 10/1/2009
Client: Adriano Tosi Address: 1012 ½ California street Huntington Beach, CA 92648 Employer: Glidewell Dental Ceramics Claim number: 91-003-280 Date Injury: 7/11/2008 DATE OF VISITS
DOCTOR/ADDRESS
MILES/ROUND TRIP
8/25/2008
Medical Image C.enter 7677 Center Av. Huntington Beach, CA.92647
12.02
09/26/08 10/15/08 10/17/08 10/20/08 10/24/08 10/27/08 10/31/08 11/03/08 11/12/08 11/17/08 11/24/08 12/01/08 12/22/08 12/29/08 01/05/09 01/12/09 01/19/09 01/23/09
California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel
16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24
9/18/08 10/30/08 12/18/08 02/12/09 03/26/09 05/21/09 07/09/09 08/27/09 09/03/09 10/15/09
Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806
Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD
40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2
2/06/09 2/13/09
Bien Physical Therapy17822 Beach Blvd Huntington Beach CA 92647 #230 Dr Richard S Bien Bien Physical Therapy17822 Beach Blvd Huntington Beach CA 92647 #230 Dr Richard S Bien
5.6 5.6
5/18/09
Pacifica Orthopedic18800 Delaware st Huntington Beach CA 92648 #1100 Dr Ahearn
3
6/30/09
Workstrategies2400 East Katella Avenue Suite 400Anaheim, CA 92646 Therapist Mark Haftak
40.2
9/29/09
3620 S Bristol St Ste 205Santa Ana, CA Dr. Kamran Hakimian
20
7/11/08 7/14/08
Procare Work Injury 17232 Red Hill Ave Irvine, CA 92614 DWCI Procare Work Injury 17232 Red Hill Ave Irvine, CA 92614 Dr Jenningi
15.5 23
Total Miles in 2008 = 684.98 x 0.585 = $400.72 Total Miles in 2009 = 400.76 x 0.55 = $231.42 Total $ amount = $632.14
Signature P.O.Box 5062 Fresno 93755 CA Telephone: 559.447.7100 Facsmile: 559.447.7180
Date
Attention to: Donna Hall Mileage Reimbursement Form Date: 10/1/2009
Client: Adriano Tosi Address: 1012 ½ California street Huntington Beach, CA 92648 Employer: Glidewell Dental Ceramics Claim number: 91-003-280 Date Injury: 7/11/2008 DATE OF VISITS
DOCTOR/ADDRESS
MILES/ROUND TRIP
8/25/2008
Medical Image C.enter 7677 Center Av. Huntington Beach, CA.92647
12.02
09/26/08 10/15/08 10/17/08 10/20/08 10/24/08 10/27/08 10/31/08 11/03/08 11/12/08 11/17/08 11/24/08 12/01/08 12/22/08 12/29/08 01/05/09 01/12/09 01/19/09 01/23/09
California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel California rehabilitation & sport therapy5772 Bolsa Av. Suit 101 Huntington Beach. CA 92649 .PT Alan Vogel
16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24 16.24
9/18/08 10/30/08 12/18/08 02/12/09 03/26/09 05/21/09 07/09/09 08/27/09 09/03/09 10/15/09
Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806 Kerlan Jobe Orthopedic Clinic2400 East Katella Avenue Suite 400Anaheim, CA 92806
Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD Dr Jae Chon MD
40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2 40.2
2/06/09 2/13/09
Bien Physical Therapy17822 Beach Blvd Huntington Beach CA 92647 #230 Dr Richard S Bien Bien Physical Therapy17822 Beach Blvd Huntington Beach CA 92647 #230 Dr Richard S Bien
5.6 5.6
5/18/09
Pacifica Orthopedic18800 Delaware st Huntington Beach CA 92648 #1100 Dr Ahearn
3
6/30/09
Workstrategies2400 East Katella Avenue Suite 400Anaheim, CA 92646 Therapist Mark Haftak
40.2
9/29/09
3620 S Bristol St Ste 205Santa Ana, CA Dr. Kamran Hakimian
20
7/11/08 7/14/08
Procare Work Injury 17232 Red Hill Ave Irvine, CA 92614 DWCI Procare Work Injury 17232 Red Hill Ave Irvine, CA 92614 Dr Jenningi
15.5 23
Total Miles in 2008 = 684.98 x 0.585 = $400.72 Total Miles in 2009 = 400.76 x 0.55 = $231.42 Total $ amount = $632.14
Signature P.O.Box 5062 Fresno 93755 CA Telephone: 559.447.7100 Facsmile: 559.447.7180
Date
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