01. Edit your or request reimbursement expenses online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send or request reimbursement expenses claim via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out View and update your claim online
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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name, address, phone number, and email. Ensure that all details are accurate to avoid delays.
Locate the 'Claim Number' field and input your specific claim number for reference.
For mileage reimbursement, fill in the travel date, start location, end location, medical purpose, total miles traveled, and the amount you are claiming.
In the pharmacy/other medical section, provide details of any medications purchased. Include the date of purchase, medication name, prescribing doctor’s name, and amount paid.
Complete the meals/lodging section by detailing travel dates and itemizing expenses for breakfast, lunch, dinner, and lodging. Attach itemized receipts as required.
Finally, review all entries for accuracy before signing and dating the form to certify that all information is true.
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