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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  1. Click ‘Get Form’ to open the Kidney Health Care Travel Claim Form in the editor.
  2. 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.
  3. 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.
  4. If your reason for travel is not listed, check the box marked ‘Other’ and provide additional details on the back of the form.
  5. 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.
  6. If applicable, have a witness sign if you are unable to sign yourself.

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You can travel abroad if you are living with kidney disease, but youll need to plan ahead to make sure you have a safe, relaxing break. We answer your questions about travelling with CKD or as a transplant recipient.
You can travel abroad if you are living with chronic kidney disease, but youll need to plan ahead to make sure you have a safe, relaxing break. We answer your questions about travelling with CKD or as a transplant recipient and explain what you need to know about Dialysis Away from Base (DAFB).
The program is available to anyone who: Lives in Texas. Has an income less than $60,000 per year. Has a diagnosis of end-stage renal disease from a licensed doctor.
Health insurance generally covers dialysis and kidney transplants, though the specific coverage details and out-of-pocket costs will depend on your insurance plan. Most employer-sponsored/private insurance plans cover: In-center or home dialysis. Surgery and hospital stay for transplant.

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Related links

American Kidney Fund: Join us in fighting kidney disease on

From prevention and research through treatment and transplant, we are dedicated to making sure kidney patients have someone fighting by their side.

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Medicare

FORM CMS-2552-10. 4002.2. 4004.2 Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire.--. The information required on Part II of

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Form 3093, KHC Travel Claim for Home Dialysis and Kidney

Provide your monthly travel details by completing all four columns of this table for each trip. On the Reason for Trip column, choose the code.

Learn more

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