Nursing Home Expense Reimbursement Form

Please complete this form to apply for reimbursement of nursing home expenses incurred on behalf of the covered family member. Attach all relevant receipts and documents before submission.

EMPLOYEE INFORMATION
Name:
Employee ID:
Department:
Contact Number:
Email Address:
PATIENT INFORMATION
Name:
Relationship to Employee:
Nursing Home Name:
Nursing Home Address:
EXPENSE DETAILS
Date of Expense:
Description of Expense:
Amount (in USD):
ADDITIONAL EXPENSES (if any)
Date of Expense:
Description of Expense:
Amount (in USD):
Total Reimbursement Requested:
DECLARATION
I hereby declare that the information provided is true and accurate to the best of my knowledge and that the expenses for which reimbursement is claimed were incurred by me for the patient as described.
Employee Signature
Date:

Instructions for Submission:

• Ensure all fields are accurately filled.

• Attach all necessary receipts and documents to this form.

• Submit the completed form and attachments to [Your Company Name]'s HR Department by [Month, Day, Year].
  

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