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To
be completed by Employee:
(Please Print)
Employee ID
____________________
First Name ____________________Last Name
__________________
c
Male
c
Female
Age:_______ D.O.B. _________/________
Contact Phone No.______________________
Email:______________________
Home Address__________________________ City
_________________ST______ ZIP_______
I request the Rebate Reimbursement Program for my flu
shot because:
c
My facility did not
hold an on-site flu clinic
c
I
was ill on the day of the clinic and was unable to take
the shot.
c
I was away from the
office on the day of the scheduled clinic for a business
meeting.
I understand that I will be reimbursed by Heart Screen
up to $20.00 for my flu shot as long as I provide a
valid, dated and signed receipt and an authorized
facility/company coupon.
________________________________Date:
__________________
Signature
Mail
Coupon with paid receipt to: .......... |