FREE 14+ Employee Medical Reimbursement Forms in PDF

Wellness programs are now offered to employees as part of the employment package that they shall receive and benefit. Most of these programs include gym memberships and regular medical checkups that aid employees to acquire a well-balanced and a healthy lifestyle. However, regardless of the wellness programs and activities that employees undergo, some illnesses and immune system issues are always around the corner of the workplace, which leads to the submission of sick leave authorization forms to the management. Associated with this sickness or illness are the expenditures that the employee needs to pay for his medical treatment and procedures, which is the exact instance when an employee medical reimbursement form will serve its purpose.

What Is an Employee Medical Reimbursement Form?

Employee medical reimbursement forms are documents that employees use to request the management and the health insurance provider of the company to cover up the employee’s medical expenses when he was on his sick leave. With the form, the insurance provider and the company will be able to determine the coverage and the amount they will reimburse for the employee. Additionally, the form can also be used for doing an accounting claim for the dependents of the employee. To secure that the reimbursement will be granted without further delay, the employee or the claimant of the medical reimbursement must enclose necessary and relevant documents to serve as proof of his sickness. The claims will then be verified by the authorized personnel and will be processed to allocate the reimbursement amount.

Medical Expense Reimbursement Request Form

Direct Payment Medical Reimbursement Form

Interactive Medical Expense Reimbursement Form

Limited Medical Expense Reimbursement Form

Medical Care Reimbursement Request Form

Steps in Filling Out an Employee Medical Reimbursement Form

It is essential that an employee medical reimbursement form has completed fields with the important details of the employee’s medical expenses. With the listed steps below, you, the user of the form, will be able to complete the document with ease:

Step 1: Complete the employee information section. Specifically, you will need to state your name, job position in the company and an indication of whether you filed a current employee change of address to the management or not. It is essential that your address and contact details are clarified on this section to allow the management and the insurance providers in reaching out to you whenever they need more of your information for verifying data about your medical reimbursements.

Step 2: State the type of medical services and its costs to be reimbursed. Whether you have undergone a surgical procedure or that you have bought medications for your illness, you must properly indicate in this section the list of everything that you spent using your personal budget. A table may be used for easier identification and classification of your medical expenditure along with their associated spent amount and the discounts that you have acquired during your purchases. Other information about the medical services you took should include the place where the service was granted, the full description of the service, and the names of the doctors who provided the services to you.

Step 3: Let your doctor indicate his diagnosis. Most companies and insurance providers need enough proof as an assurance that the claims of their clients and patients are true and validated. This is why it is vital that you must inform your medical service provider who is your doctor or surgeon who took care of you during your illness. The specification of to whom the services are to be charged is to be stated by the doctor including the doctor’s particulars which are his signature, clinic location, full name with title, contact number, and the date when he completed his allocated area of the form.

Step 4: List the documents that you enclosed with the form. The doctor’s notes, medical forms, and all receipts that you received during your stay at the hospital and the duration of your illness will need to be stated in this section. The importance of having the list of documents is to ensure that all the paperwork you have enclosed will remain intact and will be recorded by the receiving party of the form.

Step 5: Sign to certify your statements and submit. By having your signature in this section, you are certifying that the statements, claims, and all details of your medical information and illness are true and correct. Some companies include a disclosure statement in this section in order for the management and the insurance provider to gather more information and in-depth descriptions about the employee. The information is used for the investigation process of the management and for determining the actual amount to be reimbursed.

As you receive the form, secure that the information verification section has been signed by the company. This section is important as it will indicate that you have indeed claimed facts on your reimbursement and that your information has been reviewed by the authority.

Medical Expense Reimbursement Account Claim Form

Medical Expense Reimbursement Claim Form

Privately Incurred Medical Reimbursement Application Form

Medical Expenses Reimbursement Form

Medical Reimbursement Application Form

Examples of Employee Medical Reimbursement Forms

Every employee medical reimbursement form will vary on the range of services and medication that an insurance provider will grant to their employed members. With the examples below, you will be able to choose and determine what form you must use for your medical expenditures:

Limited Medical Expense Reimbursement Form – Not all medical-related incidents and absences are subjected to provide a medical reimbursement for employees in a company. With a limited medical expense reimbursement form, a company will be able to assure that they will only be giving the reimbursement for illness or incidents that are listed on the form. Specifically, this form will have the types of services that the company or the insurance provider will allow such as dental procedures, vision correction, and preventive care expenses.

Medical Treatment Reimbursement Claim Form –  Compared to other medical reimbursement forms that are used for general information of the claimant, this form deals with the detailed description of the claimant or the employee’s condition. The details include the symptoms that the employee showed, which lead to categorizing and identifying his illness, the diagnosis that the doctor provided for the employee, the types of treatments that the employee underwent to cure the illness, as well as the number of referrals and the names of the referring individuals who suggested the physician’s expertise to the patient prior to his admission.

Reimbursed Medical Expense Data Sheet – This is the form that will mainly focus on the list of dependents of the employee who requested the reimbursement and the total bill that they have paid for the medical services. The usage of the form is often for cases that demand the enforcement of medical provisions of a support order. An enclosed instruction sheet is included with this document to indicate answers regarding who will be allowed to claim the reimbursement, the limitation of the amount to be claimed, when it must be claimed, and how the claimant or the employee may acquire his reimbursed amount.

Medical Reimbursement Application Form –  This form is to be used by the employee, the employer, and the insurance provider in order to apply for a reimbursement in the insurance company. The first section of the form is allocated for the employee which should include the employee’s full legal name, social security number, reference number, tax identification number, as well as the employee’s date of birth and address. The second section of the form is for the employer who shall state the data of the company which is their registered employer number, type of employer, their contact information, address, and their website. Other details of the employee that will signify and prove that he is employed under the company will also be needed in the application, which must indicate the period of the employee’s employment, the dates when the employee was sick or absent, and the working or required service hours for the employee to provide regularly to the company as part of his signed employment contract. The last section of the form will be for the findings of the insurance company’s investigation as well as the remarks for the application process.

Medical Treatment Reimbursement Claim Form

Private Company Medical Expenses Reimbursement Form

Qualified Medical Expense Reimbursement Claim Form

Reimbursed Medical Expense Data Sheet

Medication Reimbursement Form Sample

Tips for Completing Employee Medical Reimbursement Forms

When needing to complete an employee medical reimbursement form, you must remember to gather the necessary documents before beginning filling out the form. This is to assure that you will have enough support for details about your medical condition and the amount that you will be requesting the reimbursement. Additionally, mind the dates on the documents that you enclosed as these digits may be the basis for the company and the provider to question your medical claims.

Another tip to keep in mind is to allow your physician in filling out some parts of the form especially if it requires a description of your illness. By having the knowledge and the professionalism of your physician, your company management and the insurance provider who will grant the reimbursement will have the details and answers to inquiries regarding your request. The last and the most important tip for completing any reimbursement form is to fill out the document immediately after receiving the form from the authority. The benefit of promptly completing the form is that it promotes and implies that you, as the employee, aim to settle matters formally without any prior delay.