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Personal use statement sample 2026
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- Click ‘Get Form’ to open the Personal Use Statement in the editor.
- At the top of the form, enter your name, NYS EMPLID, employer's name, patient's name, and their relationship to you.
- In the section for medically-necessary items, print the name of the item for which you are requesting reimbursement.
- Indicate the cost of the special version of that item and also provide the cost of the item in its normal form.
- Calculate and enter the difference between these two costs; this amount is what you can claim for reimbursement.
- Ensure all information is printed clearly and sign at the bottom before submitting your request along with any required documentation.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2017 | 4.8 Satisfied (245 Votes) |
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