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Get Unique Services Reimbursement Program Claim Form City Of ... - Phs
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How to fill out the Unique Services Reimbursement Program Claim Form City of Albuquerque - PHS online
The Unique Services Reimbursement Program Claim Form is essential for users seeking reimbursement for eligible services. This guide will provide clear, step-by-step instructions on how to successfully complete and submit the form online.
Follow the steps to effectively complete the reimbursement claim form.
- To begin, locate the ‘Get Form’ button to access the Unique Services Reimbursement Program Claim Form. Ensure it opens in your editor for convenient filling.
- In the Employee Information section, enter the first name, middle initial, and last name of the primary policyholder. Include the Member ID number, mailing address (note: do not use P.O. Boxes), city, state, and ZIP code. Also, provide home and work/message phone numbers, as well as an email address.
- Complete the Unique Services Reimbursement Program Request section for each eligible service received by you or your dependents. List the names, Member IDs, relationship to the primary policyholder, dates of service, types of services, and amounts incurred for each claim.
- Attach the original itemized receipts for expenses claimed. To manage smaller receipts, tape them securely to an 8 ½ X 11-inch sheet of paper. Make sure all documentation is organized and clear.
- Sign and date the form to certify the accuracy of the included information and that all claims are valid expenses for reimbursement.
- Review the form to ensure all required sections are filled out correctly. Incomplete forms or those submitted on incorrect documents will be returned.
- Finally, submit the completed form by mailing it to Presbyterian Health Plan at the provided address. Keep a copy of the form and all attached documentation for your records.
Complete your Unique Services Reimbursement Program Claim Form online today for a smooth reimbursement process.
Related links form
To apply for reimbursement using the Unique Services Reimbursement Program Claim Form City Of ... - Phs, start by obtaining the claim form from our website or local office. Complete the necessary sections accurately and gather all required supporting documents. Once your form is filled out, submit it as directed to ensure a smooth reimbursement process.
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