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Medical Reimbursement Claim Form

Employee /Dependent Name___________________________________

Date Submitted to Employer ____________________

Please attach your EOBs or receipts in order to be reimbursed for your qualifying medical

expenses.

Date of Treatment Provider Name Amount

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

__________________ ______________________________ ____________

I certify that I have not been compensated by insurance or otherwise for the above expenses.

Employee Signature ___________________________________ Date ______________________