Get Universal Reimbursement Request

This guide provides clear instructions on how to fill out the Universal Reimbursement Request online. Follow these steps to ensure your request is completed accurately and efficiently.

Follow the steps to complete the reimbursement request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of request in the designated field.
3. Fill in the applicant’s personal information, including their full name, date of birth, age, sex, and Medicaid number. Provide the applicable tabs number, address, and zip code.
4. Input the applicant’s Social Security number and the name of the school or day program they attend.
5. Complete the parent or guardian’s information, including their phone number and email address.
6. For demographic purposes, choose the appropriate ethnicity from the options provided.
7. Answer whether the applicant has previously applied for or been approved for reimbursement from any of the listed agencies, and specify which agency along with the date.
8. Indicate if the applicant has private medical insurance by checking the appropriate box.
9. Select the programs from which the applicant is receiving funding or services, if applicable.
10. List all members of the household, including their names, ages, and occupations.
11. Select the current household income range by checking the appropriate box.
12. Detail the applicant's health status and any disabilities by marking the corresponding boxes and indicating the primary disability.
13. Specify the services or goods for which funds are being requested, including anticipated costs.
14. Provide the name and Social Security number of the payee to be reimbursed, as this is required for processing.
15. Sign and date the form to attest to the accuracy of the information and acknowledgment of the reimbursement guidelines.
16. After completing the form, save any changes, then download, print, or share your completed Universal Reimbursement Request.

Complete your Universal Reimbursement Request online today to ensure timely processing.