Dean of Students Office
Off Campus Therapy Reimbursement Form
• Pomona will reimburse up to a maximum of $50 per attended appointment.
• Pomona will only reimburse for 10 attended sessions per semester.
• Reimbursement requests must be submitted with Original/Itemized Receipt.
• Receipts for reimbursement must be submitted no later than 30 days from date of your attended therapy
appointment.
Please Print Legibly
Student Name:_________________________________ Student ID Number: ____________________
Email Address: ______________________________________________________________________
Cell Phone Number: __________________________________________________________________
Type of Insurance:
Aetna SHIP Aetna HMO/PPO Blue Cross Blue Shield United Health Care
Cigna Pacificare SCAN HealthNet Kaiser Other:_____________________________
Number of receipts you are being reimbursed for:__________________________________________
Reimbursement Type: Co- Pay Co-Insurance/Payment to Doctor's Office
Name of Therapist: ____________________________________________________________________
Total Reimbursement Amount: __________________________________________________________
______________________________________________________________________________________
Student Signature
For Dean of Students Office Use Only
Total Amount Reimbursed: _____________________ Check # ________________________________
Name of DOS Staff Member: _________________________________ Date: _____________________
Signature of DOS Staff Member__________________________________________________________
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