Out-of-Network Care Service Reimbursement Form

Please use this form to request reimbursement for payments made to an Out-of-Network care provider, which is any care service provider that is not available to be booked on the UrbanSitter platform and is not subject to the Terms, including, but not limited to, the Care Provider Requirements. UrbanSitter uses the personal information you provide on this form to process your claim.

Any errors or omissions may result in delayed processing and form resubmission may be required.

Instructions

1. Book your preferred Out-of-Network provider.

2. Pay the provider directly for services rendered. Retain the receipt to submit along with your form, as the receipt will be required to process your reimbursement request.

3. Submit this form within 60 calendar days of the care service using your work email. Early submissions (before the service start date) will not be accepted. Please note that reimbursement submissions for care used in December 2026 must be received by January 31, 2027.

4. Once your request is approved, you will be sent a link to set up a Stripe Connect account. This allows you to securely connect an external bank account to receive your reimbursement. This step is not required if you already have a Stripe Connect account with UrbanSitter.

5. We're currently processing a high volume of reimbursement requests.  You will receive your ACH reimbursement to your external bank account via Stripe 4 - 6 calendar weeks after the form is approved and your Stripe Connect account set up is complete.

6. Your reimbursement amount will be limited to either the maximum reimbursement amount, or the balance remaining on your Care Credit Allowance (if applicable).

I understand that in order to process this reimbursement, UrbanSitter must use the information I have provided on this form, and I hereby consent to the processing of my personal information in accordance with UrbanSitter's Privacy Policy.

I understand that I assume all risk when using Out-of-Network Care Providers and that I am solely responsible for selecting, vetting, engaging, scheduling, making payment to and otherwise interacting with my Out-of-Network Care Provider.

I acknowledge that neither my employer nor UrbanSitter, Inc. have any knowledge concerning the employment status or qualifications of my Out-of-Network Care Providers.

I agree to release and hold harmless UrbanSitter, its affiliated parties, and my employer from any claims, demands, damages, liability, costs or expenses, sales or use taxes or value added taxes, of every kind and nature, known or unknown, suspected or unsuspected, disclosed or undisclosed, arising out of or in any way connected with my use of an Out-of-Network Care Provider or the reimbursement payment(s) made to me. UrbanSitter may deduct or withhold taxes that it determines it is obligated to deduct or withhold from any reimbursement amounts payable to me, and payment to me as reduced by such deductions or withholdings will constitute full payment and settlement to me of any reimbursement amount.

I certify that to my knowledge, the information provided in this form is accurate and complete.  I have confirmed that the expense is for qualified services from a care provider that meets the guidelines communicated to me by my employer

I have not received reimbursement for this expense before and am not expecting reimbursement for this expense to any other account.  I understand that I may be audited for compliance with my employer's guidelines and that non-compliant requests may be communicated to my employer.