Payment Request for Medical Expenses Type of Payment Request* Direct Payment to Provider Reimbursement to Patient Direct Payment: Use only one form for each provider to be paid. Reimbursement: Include up to 3 items to be reimbursed on on each form submitted. Use a separate form for each type of requestPatient InformationPatient's Name* First Last Patient's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where the reimbursement check is to be sent.Medical Provider InformationName of Medical Provider* Medical Providers Phone*Address of Medical Provider Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where a payment is to be sent.Itemized Medical ExpensesDescription and Amount of Expenditure #1*Be as detailed as possible. Be sure to include the amount to be remitted.Upload Medical Bills or Unpaid Medical Receipts #1Max. file size: 100 MB.Upload each item to be paid or reimbursed. Proof of each expenditure must be included for each request. Without proof of payment, reimbursement will be denied.Description and Amount of Expenditure #2Be as detailed as possible. Be sure to include the amount to be remitted.Upload Medical Bills or Paid Medical Receipts #2Max. file size: 100 MB.Upload each item to be paid or reimbursed. Proof of each expenditure must be included for each request. Without proof of payment, reimbursement will be denied.Description and Amount of Expenditure #3Be as detailed as possible. Be sure to include the amount to be remitted.Upload Medical Bills or Paid Medical Receipts #3Max. file size: 100 MB.Upload each item to be paid or reimbursed. Proof of each expenditure must be included for each request. Without proof of payment, reimbursement will be denied.
