Client Refund Reimbursement Form

Location:

Client name:

Patient name:

Via account number:

Original form of payment: CashCheckePay

If payment was a check, please complete the following:

Check number:

Date written:

Original payment amount:

Amount due back to client:

Make check payable to:

Mail check to:

Explanation of refund request:

Attach invoice:

*Please note: A refund can take up to 3 weeks to receive in the mail.