Personal use statement sample 2026

1. Click ‘Get Form’ to open the Personal Use Statement in the editor.
2. At the top of the form, enter your name, NYS EMPLID, employer's name, patient's name, and their relationship to you.
3. In the section for medically-necessary items, print the name of the item for which you are requesting reimbursement.
4. Indicate the cost of the special version of that item and also provide the cost of the item in its normal form.
5. Calculate and enter the difference between these two costs; this amount is what you can claim for reimbursement.
6. Ensure all information is printed clearly and sign at the bottom before submitting your request along with any required documentation.

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