Kidney Health Care Travel Claim Form 2026

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The document is a travel claim form for kidney dialysis and transplant patients, allowing them to request reimbursement for travel related to their medical care. It requires clients to provide personal information, trip details, and select reasons for their travel from a predefined list. Clients must acknowledge the accuracy of their claims and understand the legal implications of providing false information. Additional information is requested if the reason for travel is not listed. The form also includes a privacy notice regarding the client's rights.

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Click ‘Get Form’ to open the Kidney Health Care Travel Claim Form in the editor.
Begin by filling out the Client Information section. Enter your Last Name, First Name, Middle Initial, Phone Number, Social Security Number (optional), and KHC Number.
In the Trip Information section, provide details of your monthly travel by completing all four columns of the table. For the last column, select a code from the provided list that best describes your trip's purpose.
If your reason for travel is not listed, check the box marked ‘Other’ and provide additional details on the back of the form.
Complete the Client Acknowledgement section by signing to confirm that all information is accurate and that no other agency will reimburse you for these trips.
If applicable, have a witness sign if you are unable to sign yourself.

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