Get Reimbursement Form - Penquis - Penquis

Completing the Reimbursement Form for Penquis is essential for ensuring prompt and accurate reimbursement for medical-related travel expenses. This guide provides a comprehensive overview of each section of the form, assisting users in navigating the process with ease.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to acquire the form and open it for editing.
2. In the section for the date of the appointment, enter the date in the format MM/DD/YYYY. Ensure accuracy as this information is crucial for reimbursement processing.
3. Provide the name of the customer with the appointment in section A. This must match the name on the identification provided.
4. Fill in the physical address of the customer in section B. Be sure to include the street address, city, state, and zip code.
5. In section C, enter the telephone number of the customer. This should be a contact number where the customer can be reached.
6. In section D, write the name of the doctor or medical facility that the customer visited.
7. Fill out section E with the complete address of the medical facility, including the street address, city, state, and zip code.
8. Record the beginning and ending odometer readings for the trip in sections labeled Beginning Odometer (1) and Ending Odometer (2). Ensure you obtain four readings in total as outlined in the form instructions.
9. Document the Trip ID number in the designated field after filling out the odometer readings.
10. Repeat steps 8 and 9 for the return trip home, ensuring you have the correct readings recorded.
11. In section F, enter the name and address of the person to be reimbursed. It is essential to consistently print the first and last name exactly the same each time.
12. Check the box in section G if this is a new name or address for the reimbursement recipient.
13. Provide the city, state, and zip code in section H. This allows for the proper mailing of checks.
14. Enter the telephone number in section I for any follow-up communications needed by the processing department.
15. Sign the form to indicate that the appointment took place and was validated by the medical facility. Include the date received and the date billed at the bottom of the form.
16. Once all fields are accurately completed, the form may be saved, downloaded, printed, or shared as necessary.

Complete your reimbursement form online today to ensure a smooth and efficient reimbursement process.