Malpractice Reimbursement Form
All reimbursement forms are due by the 15th of each month. Approved payments will be processed with your second payroll check of the month.
Today's Date
*
-
Month
-
Day
Year
Date
Employee's Legal Name
*
First Name
Last Name
Employee's CPR Email Address
*
example@cprecovery.com
Date of Payment
*
-
Month
-
Day
Year
Date
Minimum Coverage?
*
Yes
No
Total Amount Paid
*
Pay Out Note:
Policy Number
*
Full-time?
*
Yes
No
Attach a copy of the receipt(s):
*
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Upon submission, the Accounts Payable department will be alerted for processing.
Credentialing Signature:
*
Type in your signature using your full legal name.
Today's Date
*
-
Month
-
Day
Year
Date
Date
*
-
Month
-
Day
Year
Date
Amount
*
Check Number
*
This has been completed and processed by Accounts Payable.
*
Yes
Submit
Should be Empty: