Reimbursement Claim Reimbursement Claim 2025

1. Click ‘Get Form’ to open the Reimbursement Claim in our editor.
2. Begin by entering your Enrollee Name and MIF ID #. Ensure that this information is accurate, as payment will be issued to you.
3. Fill in the Provider’s Last and First Name, along with their Address. This is crucial for identifying the service provider.
4. Indicate the Place of Service (e.g., Home, Office) and provide details for each service/item on individual rows as required.
5. For each service, enter the Date of Service From and To, Description of Service/Item, Total Unit of Service/Item, and Total Amount Billed ($).
6. Attach itemized receipts that include the provider's printed name & signature, address, phone number, date(s) of service, and paid amount.
7. Finally, certify the accuracy of your information by signing the form and providing your relationship to the enrollee before submitting it via email or mail.

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