Monthly Reimbursement Request Form
Submit your medical expense reimbursement details
Employee Information
Employee Name
*
First Name
Last Name
Month of Reimbursement
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submission Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expense Information
Expense Information
Type of Expense
*
Please Select
Health Insurance Premium
Medical Expense
Prescription Expense
Vision Expense
Dental Expense
Date Expense Was Incurred
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Amount Requested for Reimbursement
*
Description of Expense (Optional) Example: Blue Cross Blue Shield monthly premium
Upload Documentation for Expense
*
Upload a File
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Choose a file
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of
Add Item
Add Item
Documentation Upload
Employee Certification
Please check all that apply to certify the following:
*
I certify that the expense submitted is an eligible medical expense for myself or my dependents.
I certify that this expense has not been reimbursed from another source.
I certify that I maintain minimum essential health insurance coverage.
Employee Signature
*
Submit Request
Submit Request
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