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Travel claim form khc 3 2009

Travel claim form khc 3 2009-2026

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The document is a travel claim form (KHC-3) for clients undergoing home dialysis or kidney transplants, issued by Kidney Health Care in Texas. It requires personal information, details of travel related to end-stage renal disease or kidney transplant, and a declaration of understanding regarding the accuracy of the information provided. The form includes a section for additional details if the reason for travel is not listed and emphasizes the client's rights to privacy.

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Click ‘Get Form’ to open the travel claim form khc 3 2009 in the editor.
Begin by filling out your personal information in Section 1. Enter your last name, first name, middle initial, phone number, KHC number, and optionally your Social Security Number.
Move to Section 2 where you will detail your travel. Complete all four columns of the table provided. For each trip, enter the date (MM/DD/YY), name of the person or place visited along with the city or ZIP code, round trip mileage, and select a reason for your trip using the provided codes.
If your reason for travel is not listed, check the 'Other' box and provide additional details on the back of the form.
In Section 3, sign to confirm that you understand and agree to the terms regarding your travel claims. If you cannot sign, a witness signature is required.

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