FLEX / YES – Medical Expense Form

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Flex Yes - Medical Expense Request

Students have 100% insurance coverage from HCC for prescriptions and office visits for illnesses and injuries. Prescriptions must be paid for upfront and reimbursed once a claim has been processed. Please be sure that student insurance information is presented, and a claimant’s statement form has been submitted for all insured expenses. Student insurance information can be accessed at: https://www.envisageglobalinsurance.com/student-zone/greenheart/ This form applies to medical expenses not covered by insurance. Expenses not covered by HCC Medical Insurance, but covered by the FLEX and YES Grants include: • Student immunizations, required TB tests and physicals • Dental expenses not covered by insurance (pre-approval from Chicago office (flexyes@greenheart.org) required) • Eyeglasses (pre-approval from Chicago office (flexyes@greenheart.org) required) • Podiatric expenses (pre-approval from Chicago office (flexyes@greenheart.org) required) Please contact the office for approval of non-insured or prescription expenses that exceed $300.

Date(Required)

Please choose Grant program(Required)

Student Name(Required)

Student GEO ID(Required)

Prepared By(Required)

Address(Required)

City State / Province / Region ZIP / Postal Code

Email(Required)

Local Coordinator(Required)

Host Family Name(Required)

Instructions 1. Complete this form and attach invoices, bills, statements, or receipts keeping a copy for your own records 2. Please submit within 30 days of the time of the expense 3. Allow 10-15 business days for processing

Attached Receipts below

Attach Receipt 1(Required)

Max. file size: 5 MB.

Receipt 1 - Date/Description of Expense (Office visit, TB test, Physical)(Required)

Receipt 1 - Who is Payment and/or Reimbursement for? (Include Name, Address, Phone Number)(Required)

Receipt 1 - Amount Due(Required)

Attach Receipt 2

Max. file size: 5 MB.

Receipt 2 - Date/Description of Expense (Office visit, TB test, Physical)

Receipt 2 - Who is Payment and/or Reimbursement for? (include Name, Address, Phone Number)

Receipt 2 - Amount Due

Attach Receipt 3

Max. file size: 5 MB.

Receipt 3 - Date/Description of Expense (Office visit, TB test, Physical)

Receipt 3 - Who is Payment and/or Reimbursement for? (include Name, Address, Phone Number)

Receipt 3 - Amount Due

Attach Receipt 4

Max. file size: 5 MB.

Receipt 4 - Date/Description of Expense (Office visit, TB test, Physical)

Receipt 4 - Who is Payment and/or Reimbursement for? (include Name, Address, Phone Number)

Receipt 4 - Amount Due

Attach Receipt 5

Max. file size: 5 MB.

Receipt 5 - Date/Description of Expense (Office visit, TB test, Physical)

Receipt 5 - Who is Payment and/or Reimbursement for? (include Name, Address, Phone Number)

Receipt 5 - Amount Due

Total Reimbursements Due

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FLEX / YES – Medical Expense Form

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Flex Yes - Medical Expense Request

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FLEX / YES – Medical Expense Form

Start Here

Please Fill me out

Flex Yes - Medical Expense Request