VA San Diego Healthcare System

Veterans Travel Benefits Program



The following sections need to be completed by Veteran:

  1. Date you are submitting this form.
  2. Full name, Full Social Security Number, Complete Physical Address (no PO Box), Phone Numbers.
  3. Report to:  Clinic/Provider you are reporting to for appt.
  4. Reason for Reporting:  The reason you are here for scheduled appt (ie: Primary Care, Xray, Lab tests, etc)

Section:  VOUCHER FOR MILEAGE ALLOWANCE (approx half way down the front page)

From:  Where you are coming from (ie:  home address, etc.; must be a physical address/no PO Box)

To:       Where you are reporting to for appt (ie:  Mission Valley Clinic, Mission Gorge Clinic, La Jolla, etc.)

Date:   Date you are signing this voucher              Signature of Veteran:  Your signature.

IF you are filing for multiple claims during a 30-day time period, please make a note at the bottom of first page, “Multiple Claims - See Back”.  On the back page, SECTION III:   Please make a note in there if you are filing multiple claims and the time frame (ie:  This signed voucher is for appointments during January 1 through January 10, 2010, etc)

Remember, you must be ELIGIBLE to receive Mileage Reimbursement.  For more information, please call (858) 552-7575.

Please mail completed voucher to:   

VA San Diego Healthcare System
3350 La Jolla Village Drive (136C)
San Diego, CA 92161 


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