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Yes! You can use AI to fill out Physician Statement in Support of Medical Travel Reimbursement (to accompany Form OWCP-957 Part B)

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Physician Statement in Support of Medical Travel Reimbursement (to accompany Form OWCP-957 Part B), page 1
Basic · 30/100Form Complexity Index

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What this form asks for

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This Physician Statement is a critical document used within the U.S. Department of Labor's Office of Workers’ Compensation Programs (OWCP) to justify reimbursement for a claimant's travel expenses. A treating physician completes this form to certify that travel is medically necessary for authorized treatment, specialist referrals, therapy, or other related services, serving as a standing authorization to be submitted with Form OWCP-957 Part B. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields26
Pages1
Form Complexity IndexBasic, 30/100

The AI checks your answers before you download

14 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

OWCP Case Number Format and Presence

Checks that the 'OWCP Case / Claim Number' field is not empty and conforms to the expected format for federal claim numbers. This number is the primary identifier for the claim, and an incorrect or missing number will prevent the form from being associated with the correct patient file, leading to processing delays or rejection.

Patient Date of Birth Validity

Validates that the patient's 'Date of Birth' is a complete and logical date (e.g., MM/DD/YYYY) and is in the past, not a future date. Accurate birth dates are essential for patient identification and verification against claim records. An invalid or nonsensical date will cause a processing failure.

Authorization Expiration Date Logic

Ensures the 'Authorization Valid Through' date is a valid future date relative to the physician's signature date. This date defines the period for which travel reimbursement is approved. An expired or past date would render the authorization invalid, causing immediate rejection of any associated travel claims.

NPI Number Format Validation

Verifies that the 'NPI / License No.' field contains a valid 10-digit National Provider Identifier (NPI). The NPI is a unique identifier for health care providers, and a valid number is mandatory for verifying the physician's credentials and processing claims. An invalid NPI will result in the form's rejection.

Physician Phone Number Format

Validates that the physician's 'Phone' number is in a recognizable US format (e.g., 10 digits with optional formatting). This ensures that the processing agency can contact the physician's office for verification or clarification if needed. An invalid number can hinder communication and delay claim processing.

Medical Service Selection Completeness

Confirms that at least one option is selected in Section 3, 'TYPE OF MEDICAL SERVICE REQUIRING TRAVEL'. This information specifies the purpose of the travel and is required to justify the reimbursement request. Failure to select a service type makes the form incomplete and the travel purpose unclear.

And 8 more checks
  • Medical Necessity Statement Presence
  • Conditional Requirement for Special Transportation Reason
  • ICD Code Format Validation
  • Work Injury Relationship Explanation Completeness
  • Physician Signature Date Validity
  • Physician Name Consistency Check
  • Physician Signature Presence
  • Patient Information Completeness

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How to Fill Out Physician Statement for Medical Travel Reimbursement Online for Free in 2026

What the AI walks you through.

  1. Navigate to Instafill.ai and upload or select the 'Physician Statement in Support of Medical Travel Reimbursement' form.
  2. Use the AI assistant to automatically fill in the Patient/Claimant Information in Section 1, including name, OWCP case number, and date of birth.
  3. Complete Section 2 with the Treating Physician and Facility details, such as name, specialty, NPI number, and address.
  4. Indicate the type of medical service requiring travel in Section 3 and provide a detailed medical necessity statement in Section 4.
  5. Specify any special transportation needs in Section 5 and list the relevant diagnosis codes and their relationship to the work injury in Section 6.
  6. Carefully review all entered information for accuracy, then electronically sign and date the Physician Certification in Section 7.
  7. Securely download the completed statement, ready to be submitted with Form OWCP-957 Part B to the appropriate OWCP office.

Common Mistakes in Completing Physician Statement for Medical Travel Reimbursement

The ones the AI is built to catch.

Entering an Incorrect or Missing OWCP Case Number
The OWCP Case/Claim Number is the primary identifier linking this medical statement to the patient's workers' compensation file. This mistake often happens due to a simple typo or not having the number readily available. Submitting the form with an incorrect or missing number will prevent automated processing and can lead to significant delays or outright rejection of the travel reimbursement claim.
Providing a Vague or Insufficient Medical Necessity Statement
The free-text 'Medical Necessity Statement' in Section 4 requires a clear justification for the travel, not just the treatment. Physicians sometimes write brief notes like 'Follow-up visit,' which is insufficient and will likely lead to denial. To avoid this, the statement must explicitly explain why the patient must travel to that specific facility for the medically necessary and authorized treatment.
Failing to Justify the Need for Special Transportation
In Section 5, checking the box for 'Taxi / special conveyance' without providing a compelling medical reason is a common error. The justification cannot be for convenience; it must explain why the patient is medically unable to use public transit or drive. A missing or weak reason will result in the reimbursement for special transport being denied, leaving the patient to cover the cost.
Not Clearly Linking the Diagnosis to the Work Injury
Section 6 requires the physician to establish a direct relationship between the condition being treated and the accepted work injury. A failure to explicitly state this connection is a primary reason for claim denial, as OWCP only covers travel for work-related conditions. The physician must clearly write that the diagnosis is a direct result of, or a sequela to, the original compensable injury.
Submitting an Unsigned or Undated Physician Certification
The physician's signature and date in Section 7 are mandatory for the form to be considered valid. Forgetting to have the physician sign and date the form is a frequent oversight that results in an automatic rejection. Always double-check that this section is completed before submitting the form to avoid having it returned and delaying reimbursement.
Leaving the 'Authorization Valid Through' Date Blank
This form can serve as a standing authorization for a period of time, but the 'Authorization Valid Through' date in Section 1 must be filled in. If left blank, the form may be treated as a one-time authorization or rejected for being incomplete. To avoid resubmitting forms for ongoing care, the physician should enter a reasonable future date (e.g., one year) to cover the anticipated treatment period.
Submitting the Form with Illegible Handwriting
Since this form is often filled out by hand in a busy medical office, illegible writing is a major issue that can make key information like the diagnosis or physician's name unreadable. This will cause processing delays or denial. To prevent this, it is best to type the information; if the form is a non-fillable PDF, a tool like Instafill.ai can convert it into a fillable version to ensure all entries are clear and legible.
Providing Incomplete Physician or Facility Information
All fields in Section 2, especially the physician's NPI/License No. and the full facility address, must be filled out completely. Missing data prevents the claims processor from verifying the provider's credentials and the treatment location, which can halt the claim. Using an AI-powered form filling tool like Instafill.ai can help prevent this by auto-populating and validating provider information to ensure accuracy and completeness.
Submitting the Physician Statement by Itself
A critical misunderstanding is that this form is the reimbursement request itself. This document is a supporting medical statement that must accompany Form OWCP-957 Part B, the actual travel reimbursement request. Submitting this physician statement alone will not result in any payment, as it only provides the medical justification, not the travel details and costs.
Using an Incorrect or Outdated Diagnosis (ICD) Code
The ICD code entered in Section 6 must be current, specific, and directly related to the approved condition for the work injury. Using a generic, outdated, or incorrect code can trigger a manual review and potential denial if it doesn't match the information on file. The physician's office should ensure they are using the latest ICD coding standards to prevent such discrepancies.

Frequently Asked Questions About Physician Statement for Medical Travel Reimbursement

 

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This plan is for your Physician Statement for Medical Travel Reimbursement: your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.
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How does the AI fill out Physician Statement for Medical Travel Reimbursement?
You answer a few questions in plain words, or upload your insurance card. The AI reads what you give it and puts each answer into the right field of Physician Statement for Medical Travel Reimbursement, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is Physician Statement for Medical Travel Reimbursement to fill out?
Physician Statement for Medical Travel Reimbursement has a Form Complexity Index of 30 out of 100, in the basic tier: 26 fillable fields across 1 page. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of this Physician Statement form?
This form is completed by your physician to verify that you require travel to receive medically necessary treatment for your work-related injury. It serves as a standing authorization to support your travel reimbursement claims on Form OWCP-957 Part B.
Who is responsible for filling out this form?
Your treating physician must complete and sign the majority of this form. You, the patient, are responsible for providing your personal details in Section 1 and ensuring your doctor completes the rest.
Do I submit this form by itself?
No, this statement must accompany Form OWCP-957 Part B, which is the actual request for travel reimbursement. This form provides the required medical justification for the travel expenses you are claiming.
What does the 'Authorization Valid Through' date mean?
This is the date your physician sets as the end of the authorization period for your travel. To claim reimbursement for travel after this date, you will need a new, updated statement from your doctor.
What kind of information should be in the 'Medical Necessity Statement'?
In Section 4, your physician should briefly explain why travel is required for your treatment. This could include needing a specific specialist, therapy, or facility that is not available closer to your home.
My doctor says I need a taxi for appointments. Where is this noted?
Your physician should document this in Section 5 by checking 'Taxi / special conveyance required' and providing a brief reason. This justification is necessary to get reimbursement for special transportation costs.
Where do I send the completed form?
Submit this form along with your completed Form OWCP-957 Part B to the correct P.O. Box address listed at the bottom of the form. Be sure to choose the address that corresponds to your program (DFEC, DCMWC, or DEEOIC).
What is an OWCP Case / Claim Number and where do I find it?
This is the unique number assigned to your workers' compensation case, which you can find on any official correspondence from the U.S. Department of Labor about your claim. It is essential for processing your reimbursement.
Can I use this form to get reimbursed for travel to my pharmacy?
Yes, if your physician determines it is medically necessary. They would indicate this by checking the 'Pharmacy / Medical Supply' box in Section 3 and signing the form.
What happens if my doctor doesn't complete and sign this form?
Your travel reimbursement request on Form OWCP-957 Part B will likely be denied without this signed physician statement. This form is the required proof that your travel is medically necessary.
Can AI tools help me fill out this form?
Yes, services like Instafill.ai use AI to help you accurately auto-fill your personal information in Section 1. This saves time and reduces errors before you give the form to your physician to complete.
How can I use Instafill.ai to prepare this form for my doctor?
Simply upload the PDF to the Instafill.ai platform. The AI will make the fields interactive, allowing you to quickly type your patient information before printing the form for your doctor's signature.
The PDF version of this form I found online is not fillable. What should I do?
You can use a tool like Instafill.ai, which can instantly convert flat, non-fillable PDFs into interactive forms. This allows you to easily type your information directly onto the document online.
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