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Reimbursement request form 2026

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The document provides a detailed guide for submitting an Out-of-Pocket Reimbursement Request Form to Discovery Benefits. It outlines the necessary steps and information required for both medical and dependent care reimbursements, including participant information, documentation requirements, and submission methods. The form is specifically for expenses not covered by the Discovery Benefits debit card.

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Click ‘Get Form’ to open the reimbursement request form in the editor.
Begin with Step 1: Participant Information. Fill in all required fields, ensuring your information is legible. Missing details may delay processing.
Proceed to Step 2a: Medical Reimbursement Information. You can submit one receipt per form or combine multiple receipts. Enter the plan type code, date of service, merchant name, person receiving the service, a brief description, and the total amount requested.
Next, complete Step 2b: Dependent Care Reimbursement Information. Include the plan type (DCA), date range of services, provider's name, their signature, and the amount requested for reimbursement.
Finally, review and sign Step 3: Participant Certification to confirm that all information is accurate and that you are submitting eligible expenses.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (100 Votes)

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