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. Have you read the guidelines for reimbursement listed above? * Yes No Reimbursement Payable to: Name: * Mailing Address: * City: * State: * Zip: * Phone Number: * Please fill out ONE form per appointment. Form must be submitted within 7 days of the appointment. Name of Counselor: * Date of appointment: * Total Amount Billed: * Amount to be Reimbursed: Please attach a copy of the invoice or receipt. Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 516MB If you are human, leave this field blank.