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Mandel x CU Boulder Rideshare Reimbursement Request
CU Boulder students who used rideshare services to/from Mandel Dermatology can use this form to request reimbursement of up to $15 (per round trip).
Patient's First Name
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Patient's Last Name
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Patient Date of Birth
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Month
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Day
Year
Date
Visit/Rideshare Date
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Month
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Day
Year
Date
Reimbursement Details
Reimbursement Amount Requested
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Total Rideshare Cost
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(e.g. $9.88)
Please attached your detailed rideshare receipt(s).
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Please note, the receipts must show the starting and ending location, total ride cost, and trip date which match your Mandel Dermatology visit date.
Cancel
of
Receipt verification
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I understand that if my receipt(s) do not include the starting and ending location, total ride cost, and trip date which matches my Mandel Dermatology visit date my request may be denied.
Please attach a photo of your CU Boulder ID
*
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Cancel
of
Confirmation
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I confirm that the amount I am requesting is for rideshares associated only with my visit to Mandel Dermatology Boulder and that I am the patient who used the rideshare service.
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