Get Reimbursement Request Form - Eide Bailly

Completing the Reimbursement Request Form - Eide Bailly online can streamline your process for claiming expenses related to medical and dependent care. This guide provides you with a step-by-step approach to ensure all necessary information is accurately filled out for a successful submission.

Follow the steps to properly complete your reimbursement request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the benefit year at the top of the form.
3. Next, enter your employer's name accurately in the designated field.
4. Provide your Social Security Number, ensuring only the last four digits are visible for privacy.
5. Input your first name, middle initial, and last name in the respective fields.
6. Complete your address, including city, state, and zip code.
7. Insert your daytime phone number and email address to facilitate communication.
8. For unreimbursed medical and dental expenses, list the date(s) of service, person for whom the expense was incurred, and expense description.
9. Add the name of the service provider and the net amount for each expense. Repeat for additional expenses as necessary.
10. Calculate the total amount of unreimbursed medical and dental expenses claimed.
11. For unreimbursed dependent care expenses, enter the period covered and the name of the dependent.
12. Identify the provider's name, tax ID, and obtain their signature or attach a receipt.
13. Total the unreimbursed dependent care expenses claimed.
14. Review the certification statement and ensure you understand the responsibilities regarding accuracy and veracity of the claimed expenses.
15. Sign and date the form to validate your submission.
16. Finally, save the changes to the form, then download, print, or share the completed form as needed.

Start filling out the reimbursement request form online today to ensure a smooth reimbursement process.