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Reimbursement Claim Reimbursement Claim 2026
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- Click ‘Get Form’ to open the Reimbursement Claim in our editor.
- Begin by entering your Enrollee Name and MIF ID #. Ensure that this information is accurate, as payment will be issued to you.
- Fill in the Provider’s Last Name and First Name, along with their Address. This information is crucial for processing your claim.
- Indicate the Place of Service (e.g., Home, Office) and provide details for each service/item in separate rows. Include Date of Service From and To, Description of Service/Item, Total Unit of Service/Item, and Total Amount Billed.
- Attach all itemized receipts that include the provider's printed name & signature, address, phone number, date(s) of service, and paid amount. Remember to certify the accuracy of your information by signing at the bottom.
- Once completed, send your form via email to NY_DOH_MIF@pcgus.com or mail it to the specified address.
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