A reimbursement request form is a document which is used by organizations to collect data and information from their members who will want to acquire a reimbursed payment in lieu of any service or financial transaction which had been conducted.

Types of Reimbursement Request Forms

Adoption Assistance Reimbursement Request Form – There are some companies who support their employees who will be taking on an adoption, specifically in the means of providing financial aid or support. For this, an adoption assistance reimbursement request form will have to be filed by the adopting employee. In the form, there are four sections to be completed by the employee. The first section is intended for the employee’s information which is then followed by the adoption information in the second section, the eligible expenses in the third section, and an employee certification in the fourth section.

Adoption Assistance Reimbursement Request Form

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Assessment Fee Reimbursement Request Form – This is the type of form which must be filled out by students or individuals who have taken an assessment procedure wherein payments and fees are required to be provided. With the form, the student who is requesting for the reimbursement will be able to indicate his general information such as his name, address, and chosen study program.

Assessment Fee Reimbursement Request Form

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Size: 59 KB

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Bus Reimbursement Request Form – For organizations or groups in a company who will be going on a field trip or traveling for company-related events, a bus reimbursement request form can be used to ask for a reimbursement for the expenses spent in using a bus. The information to disclose in the form would be the contact information of the organization’s contact person along with the organization’s name, cell number, fax number, and the number of committed passengers, and the bus’ company information.

Bus Reimbursement Request Form

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Size: 617 KB

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Cellular Device Usage Reimbursement Request Form – Similar to the aforementioned bus reimbursement request form, a cellular device usage reimbursement request form is a document to be used by a requestor if his intent is to acquire the repayment of his expenses in utilizing the company-provided cellphone or cellular device. The requestor will have to state the type of reimbursement that he is requesting along with with his employee data and information, the details of the mobile device, the approved usage level, his justification, and the calculation of the expenses.

Cellular Device Usage Reimbursement Request Form

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Size: 143 KB

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Check Reimbursement Request Form – The number of the check to be reimbursed as well as the date stated, its amount and the payee information will have to be stated in this type of reimbursement request form. Furthermore, the name and signature of the person requesting the check along with the signature of the approving committee should also be indicated in order to complete the form.

Check Reimbursement Request Form

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Size: 25 KB

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Medical Reimbursement Request Form – Insurance companies and providers use this form to allow their insurance coverage claimants and members to supply adequate information which can be used to identify the amount to be reimbursed for the member’s medical expenses. The form will collect the name of the member who received the medical supplies and services along with the details of the member’s other insurance coverages. A set of questions for determining where the supplies and services were acquired and the type of supplies the member used for traveling will also have to be answered in the form. Moreover, the details of the member’s medical supplies and services should also be disclosed in the form, specifically the date when each service or supplies were acquired, the doctor’s diagnosis for the member’s needs, and the billed amount which had been paid by the member.

Medical Reimbursement Request Form

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Out-of-Pocket Reimbursement Request Form – Three sections comprise this form type. The participant’s details including his social security number and the name of his employer will be collected in the first section. On the other hand, the second section is for the medical reimbursement details while the last section will be for the participant’s signature to certify the accuracy of the data that he is provided in the form.

Out-of-Pocket Reimbursement Request Form

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How to Get a Reimbursement Request Form

Reimbursement request forms should only be acquired from the organization or company where the request will be submitted. In order to get the form, a requestor must inform the authorized personnel of the company who is assigned to conduct and manage financial-related requests such as reimbursements. Then, the requestor will need to fill out the form and submit it back to the company along with the required documents to prove the validity and to justify the request.

Choice Fund Reimbursement Request Form

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Size: 597 KB

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Claim Reimbursement Request Form

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Size: 165 KB

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Engineering Reimbursement Request Form

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Size: 51 KB

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Pet Accident-Illness Reimbursement Request Form

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Size: 487 KB

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Prescription Reimbursement Request Form

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Size: 89 KB

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Essential Contents of Reimbursement Request Forms

Regardless of the type of reimbursement request form that organizations will use, the form should have the following sections and contents for it to be an efficient document the financial aid department or provider can use for their reimbursement procedures:

The information of the claimant or the requestor

The details of the claimant or the person who is requesting the reimbursement will have to be documented in the form including his identification numbers, address, and contact information.

The calculations and details of the requested reimbursement

This section must have every amount of the items or the purchased goods of the requestor. Specifically, each item must be accompanied by the price that the requestor had paid along with other fees which were provided in order to obtain the item.

The certification of the claimant or the requestor

The purpose of a certification statement is to indicate that the claimant or the requestor affirms the data and information that he had disclosed and stated in the request form.

Reimbursement Request Form in DOC

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Reimbursement Request Form Sample

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Supply Reimbursement Request Form

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Size: 127 KB

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Travel Reimbursement Request Form

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Size: 1 MB

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Reimbursement Request Form Formats

When making reimbursement request forms, the document-preparer should consider making the form in varying formats such as in “.DOC”, “.PDF”, and in “.XLS” format. However, within the three formats, the rarest yet useful is the “.XLS” format and this is because with an “.XLS” format, the document-preparer can use formulas and mathematical features which will be beneficial for computing the amounts to be reimbursed to the requestor. Nevertheless, the other two formats can also be used specifically the “.PDF” format for online or electronic reimbursement request forms, and the “.DOC” format for print-out forms.

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