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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 #1Upload 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 #2Upload 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 #3Upload 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.
