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Deductible Credit Report Reimbursement Request

If you as the employer have paid out of pocket for the report from your prior medical insurance carrier, please fill the below out and you will receive a credit on your upcoming bill from BHT. Copy of payment/receipt is required.
1.Company Requesting Reimbursement
2.Address
3.Carrier that Deductible Credit Report was provided by (former medical insurance):
4.Cost of Deductible Credit Report paid:
5.Please upload copy of payment record/receipt:
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