Example: dental hygienist
Reimbursement check request form
Found 2 free book(s)Claimant Reimbursement Forms - DOL
owcpmed.dol.govcancelled check or credit card slip) 2. It is recommended (but not required) to have your provider complete a medical, dental, or facility reimbursement form. The HCFA 1500 form is a good example. These forms can be submitted along with your 915 form to ensure your bill is coded correctly and you are reimbursed for the proper services.
Request for Reimbursement - myuhc
www.myuhc.comUse this Request for Reimbursement form to ask for payment from your FSA for eligible care you’ve already received. What expenses are eligible? u A general list of eligible expenses and frequently asked questions is available on your member website. u Don’t miss the deadline: Your request must be postmarked before the submission deadline,