Get American Fidelity Medical Reimbursement Claim Form

Navigating the American Fidelity Medical Reimbursement Claim Form can be straightforward with the right guidance. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your reimbursement claim form.

1. Press the ‘Get Form’ button to access the American Fidelity Medical Reimbursement Claim Form and open it in your preferred editor.
2. Enter your name as it appears on your identification, including last name, first name, and middle initial.
3. Provide your mailing address to receive any correspondence regarding your claim.
4. Input your Social Security number for identification purposes.
5. Fill in your email address to ensure you can receive notifications and updates.
6. Check the box indicating if you have changed your address recently.
7. Write the name of your employer to associate your claim with the correct account.
8. Specify the date of the medical expense incurred.
9. Provide your daytime phone number for any necessary follow-up.
10. Indicate the name of the person for whom the expense was incurred, if different from you.
11. Indicate whether the expense is eligible under state tax law for dependents.
12. Enter the total amount of the medical expense incurred and ensure it is accurate.
13. Attach detailed documentation for each service rendered, such as professional bills or receipts, ensuring each includes date, type, and amount.
14. Review your information for accuracy and completeness, ensuring all required fields are filled out.
15. Once completed, save your changes, download a copy, print it for your records, or share as needed.

Begin your online claims process now by filling out the American Fidelity Medical Reimbursement Claim Form.