Counseling Reimbursement Form

Counseling Reimbursement Form
1. Your counseling benefit is set for $1,000 per year.
2. You will only be reimbursed for 80% of the cost until you have reached the maximum.
3. We are not able to reimburse for the cost of missed appointments.
4. A check will be issued and mailed to you within 2-3 weeks.
5. For accounting purposes, each form must be submitted within 7 days of the appointment.
*Please know this information is kept private and confidential.

Reimbursement Payable to:

Please fill out ONE form per appointment. Form must be submitted within 7 days of the appointment.

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