Staff Counseling Reimbursements

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.

Maximum upload size: 516MB

Counseling Reimbursement Form

Reimbursement Payable to:

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