Coop Inst

Surrogate Expense Reimbursement Form

Name: IP's Name

Address:

$

$

Dates Required

Travel/Mileage Reimbursement (After mile 25 round trip) $0.54 or

$0.58

(Check one)

See your contract

$

Dates/Travel Maps Required/Please indicate the reason of each trip Medical Co-Pays/Bills/Premium Reimbursement $

$

$ Dates & Attach Receipts/Invoice Required

$

Dates, reason, pay stub and state disability breakdown required Invasive Procedure

(Provide procedure details)

$

Dates Required

Bed Rest/Restriction of Activity

weeks on bed rest x $ SEE your contract

$

Doctor's order must be provided along with dates

Breast Milk Pumping weeks x $200 $

Dates Required/Receipts Required

Misc $

Dates Required/explanation/proof

Total amount due $

This reimbursement form MUST be submitted no later than the 20th of every month for the expenses to be added to the following first of the months compensation. All receipts/maps/proof/explanations must be provided every month or you can not request reimbursement. No pictures accepted, everything needs to be scanned in ONE PDF document and emailed. If you do not have a scanner at home you can download a scan app to your phone. Signature: Date:

Monthly NON Accountable Allowance

Monthly Main Compensation

Twins Payment

$

Pumping Supplies/Shipping $

$

$

Mileage Total for all trips miles x

EX:round trip 100 miles-25. Total amount to reimburse =75 miles Due Date (If you have one)

Delivery Date

Transfer Date(If scheduled) Month of

Payment # of 10

Twins Payment # of 5

Transfer Fee

Medication Start Fee

Positive HCG Fee $

$

$

Lost Wages of hours x Net hourly rate

(If on SDI) week(s) x Net weekly Pay See your contract for Lost Wage Terms. Cannot exceed terms of contract. Date

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