|
Name
|
| |
Test
|
|
Clinic
|
| |
Chicago
|
|
Week
|
| |
05/14/2023
|
|
Currency of Claim
|
| |
USD
|
| Expenses For Claim |
|
Expenses
|
| |
| Date |
Fee |
Meal per diem |
Air Fare |
Hotel |
Car Rental |
Taxi |
Parking |
Other |
Expenses |
| Sunday |
$10.00 |
|
|
|
|
|
|
|
$0.00 |
|
$10.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
|
|
Expense Sub Total
|
| |
$0.00
|
|
Fee Sub Total
|
| |
$10.00
|
|
Fee Tax Rate (Optional)
|
| |
0.13
|
|
Total Claim Submission
|
| |
$11.30
|
|
Claim Confirmation
|
| |
 I, Test agree the above amount to be accurate.
|
|