Surrogate Expense Reimbursement Form — Online Submission

Expense Reimbursement Request

Form to submit for reimbursement of expenses related to your surrogacy journey.
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed? For mileage reimbursement, please enter the number of miles driven. For all other expenses, please input the dollar amount being requested in reimbursement. NOTE: The entry on the form will not reflect a dollar sign.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form. Please Note: Per diem reimbursement is listed at the bottom of the form.
  • How much do you need reimbursed? For mileage reimbursement, please enter the number of miles driven. For all other expenses, please input the dollar amount being requested in reimbursement. NOTE: The entry on the form will not reflect a dollar sign.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form. Please Note: Per diem reimbursement is listed at the bottom of the form.
  • How much do you need reimbursed (you may include the amount either in dollars or number of miles). Please input a number representing the amount of miles driven or the expense incurred. NOTE: The entry on the form will not reflect a dollar sign.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form. Please Note: Per diem reimbursement is listed at the bottom of the form.
  • How much do you need reimbursed? For mileage reimbursement, please enter the number of miles driven. For all other expenses, please input the dollar amount being requested in reimbursement. NOTE: The entry on the form will not reflect a dollar sign.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form. Please Note: Per diem reimbursement is listed at the bottom of the form.
  • How much do you need reimbursed (you may include the amount either in dollars or number of miles). Please input a number representing the amount of miles driven or the expense incurred. NOTE: The entry on the form will not reflect a dollar sign.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
  • For reimbursement of your Per Diem (daily meal allowance) please enter the first or starting date on which you want your Per Diem paid.
  • For reimbursement of your Per Diem (daily meal allowance) please enter the last or ending date for which you are requesting reimbursment of your Per Diem.
  • Please enter a value between 1 and 2.
    Please identify whether you are requesting reimbursement for yourself or yourself and a companion. Please Note: The maximum value permitted is 2. If you are requesting reimbursement for more than two people please provide an explanation in the comment section below.
  • Please enter the total number of days for which you need to be reimbursed your Per Diem.
  • Please input the total amount of the Per Diem being requested. For example if your Per Diem is $50.00 per day and you are requesting two days, please input $100.00.
  • Unless provided as an attachment above, please provide a link to MapQuest evidencing the route your drove (the roundtrip route if you you drove both ways) to document mileage incurred. Mileage will not be reimbursed without a printout of the route attached as a receipt or a link provided here.
  • Drop files here or
    Please attach a copy of your medical bill or other receipt evidencing the amount of the expense. Please attach a receipt or other document for every item requested on this form. Mileage will not be reimbursed without a printout of the route attached here as a receipt or included as a link below. Please also note that a red circle with an x inside it means that your file is attached. It is NOT an error message.
  • Please add any additional information you think TSEMCI might need in order to process your request.
    Have you provided all information TSEMCI needs in order to process your request? Forms submitted and not properly documented will not be processed and thus delay the time in which you receive your reimbursement. Please use the following checklist to ensure you are submitting a properly completed form for reimbursement of an expense.
  • Please provide your email address in case we have any questions.
  • This field is for validation purposes and should be left unchanged.