GENERAL REIMBURSEMENT FORM - DO NOT USE FOR 2025

1. Click ‘Get Form’ to open the GENERAL REIMBURSEMENT FORM in the editor.
2. Begin by entering the Patient Name. You can add multiple lines for different services, but ensure each line contains only one date of service and procedure code.
3. Next, input the Patient MIF ID # in the designated field to help identify the member.
4. Fill in the Provider's Last Name and First Name, followed by their Address. This information is crucial for processing your reimbursement.
5. In the Diagnosis section, provide a brief description of the medical condition treated.
6. Indicate the Place of Service and enter the Claim Line Number associated with each service rendered.
7. Specify the Date of Service From and To, ensuring accuracy for reimbursement eligibility.
8. Describe each service provided in detail in the Description of Service field.
9. Finally, complete Total Quantity Billed Per line and certify that all information is accurate before signing electronically or printing for submission.

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