Claim Reimbursement Request Form Sample Clauses

Claim Reimbursement Request Form. When you elect to have Blue Cross and Blue Shield work with your designated vendor for your Account-Based Offerings, you will provide Blue Cross and Blue Shield with a completed Claim Reimbursement Request Form that designates certain aspects of the Account-Based Offerings that you will make available to your eligible employees.
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Related to Claim Reimbursement Request Form

  • Reimbursement Requests This is a cost-reimbursement Agreement. Disbursement of funds under this Agreement may be requested only for necessary, reasonable, and allowable costs described in PART B, and for which the Subrecipient has made payment during the period of performance set forth in Section 2.1 above. The City agrees to reimburse the Subrecipient for such costs, and payment shall be made upon receipt of a request for reimbursement form (PART C) accompanied by a monthly accomplishment report from the Subrecipient specifying the services performed and expenses incurred. All requests for reimbursement must be accompanied by two sets of documentation: 1) case file data which confirms eligibility of the clients on whose behalf payments have been made; and 2) documentation of payment for eligible expenses (i.e., invoices, receipts, bills from vendors, copies of checks, time sheets, etc.), copies of checks from other grants etc.) received and expended, and other supporting documentation. Supporting documentation must be accompanied by an agency payment voucher providing this information and a copy of the signed check with which the payment was made. Requests for reimbursement must be received by the 15th day of the month following the month during which the expense was paid.

  • Payment Requests Review applications for payment with Contractor for compliance with the established procedure for their submission and forward with recommendations to Engineer, noting particularly the relationship of the payment requested to the schedule of values, Work completed, and materials and equipment delivered at the Site but not incorporated in the Work.

  • Reimbursement Procedure Reimbursement shall be made upon successful completion of a course with a grade of C (2.00) or better. The employee shall submit an official transcript or certificate demonstrating successful completion of the course and a receipt from the institution confirming the employee has paid for tuition, fees, and required textbooks. Any financial assistance available to an employee shall be deducted from the amount of tuition reimbursement that would otherwise be payable. The employee shall not be reimbursed for incidental expenses such as paper or supplies, mileage, parking, meals, or other expenses other than tuition, fees, and required textbooks.

  • Expense Reimbursement The Executive shall be entitled to receive reimbursement for all appropriate business expenses incurred by him in connection with his duties under this Agreement in accordance with the policies of the Company as in effect from time to time.

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