1. Application is complete and signed by both the patient’s guardian and the Recommending healthcare provider.
2. In the case of attached receipts and support documentation, we should receive the following:
- Transportation: Attach a description of required travel for treatment including treatment dates, to/from destination and either gas receipts for respective dates or mileage amounts for each specific reimbursement date being requested. If mileage is requested, we will reimburse at a rate of $.20 per mile which is the approved IRS rate for medical mileage. We will either reimburse for mileage or gas receipts but not a combination of the two.
- Medical Supplies: Include description of supplies or equipment being requested and corresponding receipt evidencing payment of equipment.
- Medication: Include corresponding receipts for prescribed medication or over the counter medication needed. We will reimburse any out of pocket costs not covered by insurance.
- Insurance Co Payment and Deductibles: Attach receipts for payment of any co-payment and/ or deductibles either for doctor visits, hospital stays, or medical care incurred for patient.
3. All receipts should fall within the treatment dates shown in the application.
4. Household Income Information – Attach latest Income Tax return for said household.