Medical Travel Reimbursement Form

Medical Travel Reimbursement Form
Please complete this form for reimbursement for certain travel expenses related to obtaining medical services. To be eligible, your employer must opt into this benefit. Please check your Summary Plan Description to determine if you have the travel benefit. Final benefit determination will be made upon receipt and review of your claim.
Employee Information
Employee Full Name

First NameLast Name
Member ID Number
(Located on the front of Medical ID card)
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Name
Employer's Group ID Number
(Located on the front of Medical ID card)
Claim Information
Member's Full Name

First NameLast Name
Member ID Number
Located on the front of Medical ID card
Date of Birth

MonthDayYear
Date
This claim reimbursement is for (choose one)

Other
Travel Information

Your companion's travel costs will also be reimbursed if the companion's presence is necessary for you to receive the medical services. Please include their costs in the totals below.
Did you travel with a companion?
Date of Covered Service

MonthDayYear
Date
Save and attach all of your receipts, and fill out the following as applicable:
Start Date of Travel

MonthDayYear
Date
End Date of Travel

MonthDayYear
Date
Start Location
End Location
Total Driven Miles (Round Trip)
Cost of Airfare
All Other Covered Transportation
Total Cost of Lodging
Number of Nights
Total Travel Cost (Including Transportation and Lodging)
*PLEASE NOTE: Form should only be submitted after travel has concluded.
Attached Receipts

(Limit of 5 files)
Cancelof
Please note:

The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size.

Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf

Please ensure the file name is 25 characters or less.
Authorization & Signature
Important Information & Reminders
- Confirm all paid receipts have been attached with form when submitting.
- Reimbursement may be considered taxable income, so you should consult your tax advisor.
- Certification and Authorization (This form must be signed and dated below.)
I certify that the information provided in support of this submission is complete and correct, and that I have not previously submitted for these purchases.

I understand that Cobalt Benefits Group may require proof of payment for a reimbursement decision. I authorize the release of any information about purchases to Cobalt Benefits Group.
Signature

Please sign with mouse or finger if on mobile device.
Date

MonthDayYear
Date
Should be Empty:

Medical Travel Reimbursement Form

Employee Information

Claim Information

Travel Information

Save and attach all of your receipts, and fill out the following as applicable:

*PLEASE NOTE: Form should only be submitted after travel has concluded.

Authorization & Signature