Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the patient's name and ID. Ensure that the information is accurate, as this helps in identifying the expenses related to the correct individual.
3. Proceed to Section 1, where you will list the first expense. Select the type of service rendered—options include Physician Office Services, Pharmacy, Outpatient Hospital Services, or Other. Then, fill in the date the product or service was received in the MM/DD/YYYY format, followed by the amount you are requesting for reimbursement.
4. Next, indicate who the check should be made payable to and provide the address, city, state, and zip code. This information is crucial for ensuring the payment reaches the appropriate recipient.
5. If you have a second expense, repeat the process in Section 2. Fill in the relevant details just as you did in Section 1.
6. In Section 3, you will need to review the declaration statement carefully. Sign and date the form to attest that all information provided is complete and accurate. Your signature confirms your understanding of potential penalties for providing false information.
7. Finally, ensure that all required documentation, such as invoices or receipts, is attached. You can then save your changes, download, or print the completed form for submission.
8. Submit the completed form and documentation either by mailing it to the specified address or faxing it to the provided number.

Start your reimbursement process today by completing your Proof Of Expenditure form online.