This form is an instrument used for making reimbursements made by patients or parents of patients who made payment advances for medical treatment or check-up that is covered by a healthcare service, employer, Medicare, or HMO. This form itemizes the information about the purpose of treatment or medical process made on the patient and shows the cost of treatment. There are instances where treatments made could not be covered by health insurance right away. In such cases, the patient temporarily assumes the cost for the treatment and asks for reimbursement. Having a form makes it simple for providers to process the request for reimbursement by receiving requests and reading through the contents in a proper format.