Medical Reimbursement Application

Medical Reimbursement Application

SD 308 staff enrolled in the PPO or HCA insurance plan and their enrolled dependents are eligible for reimbursement of co-insurance (out-of-pocket percentage) and deductible expenses for services provided by Rush employed providers and facilities, with the exception of the emergency room.
Employee Information

Insurance Subscriber
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Work Email*
example@example.com
Patient Information
Patient's Name*

First NameLast Name
Patient's Birth Date*

MonthDayYear
Relationship to Insured Member*

SelfSpouseSonDaughter
Insurance Policy Number*
Medical Expenses

Enter details on any expenses you're applying for reimbursement of:*

	Date of Service	Patient Name	Physican / Provider Name	Claim #	Total Charges
1.

Payment Information
I have paid the expense(s) listed above out-of-pocket, not using funds from a Healthcare Savings Account.*

Yes
Verification
Upload Explanation of Benefits for Services Provided Including Location and Name of Provider(s).*

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Upload a receipt or proof of payment including amount paid.*

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Sign to verify all data is correct*

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