Reimbursement Request Form
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REIMBURSEMENT REQUEST
This Claim Form with original itemized bills & receipts and all correspondence should be mailed to:
HEALTH & SOCIAL SERVICES
10100 S. Bluejacket Rd., Ste. 1
Wyandotte OK 74370
Within 90 days of the date you first received your expenses
DO NOT submit a claim unless your total expenses meet the $25 minimum requirement
Please complete all relevant sections of this form. Original documentation (itemized bills & receipts) must be submitted with this form.
Photocopies of documents are NOT acceptable.
PLEASE NOTE: All claims must be incurred during the fiscal year (Oct 1—Sep 30.) Processing time could be delayed if proper documen-
tation is not provided.
**IMPORTANT: For any questions about the program please call us at (918) 666-7710 or toll free at (866) 978-1352**
TRIBAL MEMBER INFORMATION (ONLY ONE MEMBER PER FORM)
Name:
____________________________________________________________
Tribal ID #:
____________________
Address: ____________________________________________________________
Date of Birth: _____________________
____________________________________________________________
Address Change
E-Mail Address: _______________________________________________________
Work
Home
New
Phone Number Where You May Be Reached: (
)
-
Telephone Change
LIST ELIGIBLE SERVICES AND EXPENSES FOR YOU AND YOUR FAMILY THAT YOU HAVE NOT ALREADY CLAIMED THROUGH
ANY INSURANCE, MEDICARE OR MEDICAID PLAN. ONLY LIST THE AMOUNT OF THE EXPENSES YOU HAVE TO PAY AFTER
INSURANCE PAYS ITS SHARE.
*PLEASE DO NOT USE HIGHLIGHTER, STAPLES OR TAPE RECEIPTS.
Types of Expenses
Dates Incurred
Total Out-of-Pocket Expenses
Total School Expense Reimbursement Requested
From _________ To _________
$ __________
Total Health Care Reimbursement Requested
From _________ To _________
$ __________
Total Orthodontic Reimbursement Requested
From _________ To _________
$ __________
Total Auditory Devices Reimbursement Requested
From _________ To _________
$ __________
Total Special Medical Equipment Reimbursement Requested
From _________ To _________
$ __________
Total Burial Reimbursement Requested
From _________ To _________
$ __________
Total Disabled/Elder Care Reimbursement Requested
From _________ To _________
$ __________
Total Utilities Reimbursement Requested
From _________ To _________
$ __________
Total Reimbursement Requested
$ __________
$0.00
*** IF ANY OF THESE EXPENSES WERE COVERED BY INSURANCE, ATTACH A COPY OF THE EXPLANATION OF BENEFITS FROM
YOUR INSURANCE COMPANY SHOWING YOUR OUT-OF-POCKET EXPENSES, WITH PROOF OF PAYMENT. FOR EXPENSES NOT
COVERED BY INSURANCE, SEND THE ORIGINAL ITEMIZED STATEMENT IDENTIFYING THE SERVICE, SERVICE DATE, TOTAL
CHARGES AND ANY DISCOUNTS. IF THE REQUIRED DOCUMENTATION IS NOT ATTACHED, YOUR REIMBURSEMENT WILL BE
DELAYED.
CERTIFICATION: Signature Required
*(Parent or Guardian in case of minor child)
I certify that the above expenses were incurred by me (and/or my spouse and/or eligible dependents) and have been incurred within the current
fiscal year and were not reimbursed by any other plan, and to the best of my knowledge and belief, are eligible for reimbursement. I have
attached proof of school enrollment and documentation from the school (when necessary) and the Explanation of Benefits statements from all
insurance plans and a letter of medical necessity (when necessary) of these expenses.
Tribal Members Signature: __________________________________________________
Date: _________________________
Did you remember to:
*Sign and date your reimbursement form
*Attach your receipts
*Provide proper documentation
*Make copies of all documentation for your records
Failure to complete all appropriate sections of the reimbursement form or submit legible itemized receipts/EOBs may delay
the processing of your claim and may result in your claim being returned to you.
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