Resident Multi-site Call Travel Reimbursement Form

This form is for MOH funded residents only working city-wide or multi-site (at least 2 sites) call to claim reimbursement for travel costs (gas mileage) or for those without an HHSC/SJH parking pass taxi/parking receipts incurred while travelling between hospital sites during their call shift and are required to be in the hospital between 6pm and 6am (see Article 19.7 of the 2008-2011 PAIRO-CAHO agreement).

NB: Travel from the resident’s home to a hospital site and vice versa is not covered (i.e. there is no reimbursement for the initial trip from home to a hospital site, or for the final trip from a hospital site to home, only for travel BETWEEN hospital sites for clinical care purposes).

To claim reimbursement, either submit taxi/parking receipts (for those without parking passes) or record the number of trips occurring between each pair of hospital sites, multiply by the reimbursement rate, and tally the total amount for reimbursement. The reimbursement rate is $0.44/km, using the shortest driving distance between hospital sites. The site travel amount is shown for you on the attached form.

Deadline for submitting claims:

30 days after the end of month in which the call was worked except for the month of March. March travel MUST be submitted by April 2 in order to be processed before the Hospital’s year end.

Guidelines:

Taxi Charges: Residents on home call may be reimbursed up to $70 per month for taxi charges if:

  1. The resident is on home call and can respond within the Hospital’s Medical Advisory Committee (MAC) approved response time.
  2. The resident does not have a parking pass.
  3. The resident is called in for clinical duties after 6:00 p.m. and before 6:00 a.m.

If you have a parking pass:

  1. You will be reimbursed your mileage from site to site travel as outlined on the form below. If your parking pass does not include multi-site parking, you will be reimbursed parking or mileage, not both.
  2. If you are on home call at one site and called to another site, you will only be reimbursed travel one way. For example, if you are at MUMC Site and are called to the Juravinski Site, your travel reimbursement for should only include a travel reimbursement requested for $4.09 (one-way travel from MUMC to JH).

Submission Process:

  1. Complete the “Resident Multi-Site Call Travel Reimbursement Form” as well as the Hamilton Health Sciences “Employee Mileage/Km Reimbursement” form. Full name and HHS Employee ID number must be included in order to process this payment by direct deposit. Any Incomplete forms will be returned and will need to be resubmitted before the deadline.
  2. Email indicating you have mailed your original form and receipts (if applicable). Make sure and keep a copy for your records as proof of submission.
  3. Ensure that your taxi receipt does not include a tip amount as this will not be reimbursed.

Name (print clearly): / Date of Call: (you need a different form for each date)
HHS Employee Number (6 digits): / Your Home Program:
Your Email Address: / Service Covered:
Type of Call Covered:
Home Call  In-Hospital  / Your Mailing Address:
Car Trips Between HGH & MUMC / Set Travel Rate $ 3.39per trip
7.7 km
Between HGH & SJH / Set Travel Rate $ 2.11 per trip
4.8 km
Between HGH & JH / Set Travel Rate $ 2.38per trip
5.4 km
Between MUMC & SJH / Set Travel Rate $ 2.55per trip
5.8 km
Between MUMC & JH / Set Travel Rate $ 4.09per trip
9.3 km
Between SJH & JH / Set Travel Rate $ 1.14per trip
2.6 km
Taxi/Parking receipts (please attach original SIGNED receipt) to this sheet and submit it by mail ONLY (Remember: To qualify for this line item you cannot have a parking pass)*
Total Amount for Reimbursement :

HGH: Hamilton General Hospital MUMC: McMaster University Medical Centre

JH: Juravinski HospitalSJH: St. Josephs Hospital

______

Resident’s SignatureResident’s Printed NameDate submitted

Submit the completed form to:

Lori Arbeau | Medical Affairs Specialist | Hamilton Health Sciences,

293 Wellington Street North, Suite 119, Hamilton, ON L8L 8E7

*All Receipt related forms must be submitted BY MAIL and original receipts must be submitted. For non-taxi related submissions, you may Fax to (905) 577-1498 or electronically by sending a scanned copy with your signature) to .)

Note: Claims may be audited; Please keep a copy of all the materials you mail in to HHSC Medical Affairs, this is for your own records in case they get lost in the mail.

Rev. Sept. 9, 2014