DO NOT FAX – Faxed invoices will not be accepted except from Canada (Canadians may fax to (415) 499-4035) Name: Veterinary Expense Reimbursement Request Form Address: City/State/Zip: Mail Request to: Guide Dogs for the Blind Dog Name and Tattoo: Attn: Accounting Dept. P O Box 151200 Current Status: San Rafael, CA 94915-1200 Date of Birth: Accounting Code: (for accounting use only) Name of Clinic/Person to be Paid: Treatment Date: Invoice #: Name: Total Charges: $ Address: Less Discount/Donation: $ City: State: Zip: Total Reimbursement Request: $ Phone: Donation Made By: E-mail: Approval #: Mail this completed reimbursement form with a detailed invoice/receipt to the above address. Reimbursement requests must be submitted to GDB within 90 days of the date on the invoice/ receipt. Due to administrative constraints GDB will not consider requests for reimbursement on receipts older than 90 days. Our veterinary reimbursement program runs on a fiscal year from July 1 to June 30. GDB restricts procedures and products we will reimburse for. Please review the Veterinary Financial Assistance policy (viewable online at www.guidedogs.com/vet) prior to submitting your request. Questions? Call (800) 295-4050 and ask for extension 4117 For questions about payment status or submitting an invoice, press 1 For questions about treatment authorization or veterinary care decisions, press 2 Thank you for providing quality care to our dogs! Donating services assists us in fulfilling our mission. As a non-profit organization, Guide Dogs for the Blind relies upon generous donations from many individuals and organizations. We greatly appreciate any discounted veterinary services. Diagnoses: Please provide diagnosis related to this visit. Location: Right: Left: 1. 2. 3.