mileage report/patient bonus

Name

First Name

Last Name

Date of Event:

YYYY

Job Site Name:

Please be consistent with names provided in "When I Work" app.

Round Trip Mileage:

Mileage is paid at the federal standard rate for trips to job sites.

Patient Count:

Minimum of 35 patients.

Unit Number:

alinea Medical Imaging:

2475 N Garey Ave Pomona, CA 91767
Ph: (909) 622-3166 | Fax: (909) 622-8046

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