medical Reimbursement of Medical Dental Insurance The

							                     Reimbursement of Medical/Dental Insurance
The ASM/NCID award includes health benefits to you as a single or family subscriber. Up to
$3,500 annually is available for premium expenses with a health care provider. This amount
may not be used for out of pocket medical expenses, co-payments and/or deductibles.

DOCUMENTATION OF INSURANCE EXPENSES

Submit the following as documentation for insurance expenses:

   Proof of insurance such as Policy Statement or receipt of payment from insurance company
   indicating breakdown of premium, if policy covers more than one individual; or

   Cancelled check indicating payment of insurance and/or documentation to show proof of
   prepayment of insurance coverage.

ASM will only reimburse the cost for your insurance coverage as a single and family
subscriber.

Insurance expenses may be submitted for monthly, bi-monthly, semi-annual or annual basis
depending upon coverage period of individual’s payment to insurance company.

PAYMENT SCHEDULE

Payment for insurance expenses will be made according to the payment plan option that you
select with your insurance carrier. For example, an individual who selects a monthly insurance
plan option will receive payment each month after submission of proper documentation and an
individual who selects a six-month insurance plan, will receive payment twice a year.

Please know that the insurance payment checks will be mailed separately from the stipend
payments.

ASM CONTACT FOR HEALTH BENEFITS RELATED ISSUES

Mary Nyingi is the staff person responsible for all insurance related issues. If you have any
questions regarding health benefits, please contact Mary at 202-942-9283 or e-mail at
mnyingi@asmusa.org.

Please mail all receipts and/or documentation to: Mary Nyingi, Coordinator, Student
Fellowships, American Society for Microbiology, 1752 N Street, NW, Washington, D.C. 20036
or fax to 202-942-9329.
     ASM/NCID POST-DOCTORAL RESEARCH ASSOCIATES PROGRAM
               HEALTHCARE EXPENSE PAYMENT FORM


Name: ________________________________________________________________

Mailing Address: ________________________________________________________

______________________________________________________________________

______________________________________________________________________

Telephone: _____________________             E-mail: _____________________________

Program start date: ____________________________

Program end date: ____________________________


Indicate the insurance coverage:

Individual ___________
Family ______________


Indicate the type of insurance:

Health _________________
Dental _________________

(Note that the maximum allowable expense per fellowship year is up to $3,500.00)

Indicate the duration of premium:

Monthly: ______ Amount: __________           Quarterly: ______ Amount:
____________

Half yearly: ____ Amount: ___________ Yearly: _________ Amount: ____________

Please complete this form and return it along with the necessary receipts to:

Mary Nyingi
Coordinator - Student Fellowship Programs
American Society for Microbiology
1752 N Street, NW
Washington, DC 20036

Fax: 202/942-9329