Appendix F - BEN Health Insurance Form.pdf
PDF 107 KB Posted
- Attached to
- BEN Case Management System
- Solicitation number
- 90DETR-S3794
- Issued by
- Churchill County, Nevada
About this file
This is a health insurance reimbursement form appendix associated with the Nevada Department of Employment, Training and Rehabilitation (DETR) Business Enterprises of Nevada (BEN) program's Case Management System procurement. The form serves as a template for blind vendors and their family members to request reimbursement for medical expenses incurred, including physician visits, specialized medical services, dental care, psychological counseling, vision services, medical equipment, prescriptions, transportation, and health insurance costs. Vendors must document the name and location of service providers, indicate whether they carry other insurance coverage, and provide total amounts paid by both the vendor and any applicable insurance carriers. The form requires submission of all supporting receipts and documentation of insurance coverage to substantiate reimbursement requests.
The reimbursement form is a supporting document within the broader BEN Case Management System procurement, which seeks a web-based, cloud-hosted SaaS platform to standardize workflows for blind and visually impaired food service and vending business operators. The form demonstrates one of the various workflow processes the case management system must accommodate for BEN program participants. As a supporting exhibit rather than a standalone procurement document, this form does not contain independent pricing terms, set-asides, incumbent information, or contract award details; those elements are governed by the primary RFP for the case management system itself, with proposals due May 22, 2026, and an anticipated contract start date of September 8, 2026, for a four-year term.
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Text version
Blind Vendor Health Insurance Reimbursement Form
Vendor Name
Patient Name
Date Submitted
Type of Medical Service
Physician Visit ☐ Specialized Medical ☐
Dental Visit ☐ Psychological/Counseling ☐
Vision ☐ Equipment ☐
Prescription ☐ Transportation ☐
Health Insurance ☐
Name, Address and Phone Number of Where Services Were Performed
Is Vendor / Family Member Covered by Other Insurance? ☐ Yes ☐ No
If Yes, Please Provide Insurance Information
Total Paid by Vendor $
Total Paid by Insurance $
Please attach ALL receipts for the requested reimbursements.
If you or your dependents are covered by other insurance, please attach a copy of what your insurance carrier has covered.
It is the Vendor’s responsibility to provide proof of payment by himself / herself and / or the insurance company.
| Vendor Name: |
| Patient Name: |
| Date Submitted: |
| Name Address and Phone Number of Where Services Were Performed 1: |
| Name Address and Phone Number of Where Services Were Performed 2: |
| Total Paid by Vendor: |
| Total Paid by Insurance: |
| No: Off |
| Yes: Off |
| Physician Visit: Off |
| Dental Visit: Off |
| Vision: Off |
| Prescription: Off |
| Health Insurance: Off |
| specialized medical: Off |
| Psychological - counseling: Off |
| Equipment: Off |
| Transportation: Off |
File details come from the government source that posted it. Updated .