Start by filling out your personal information. Include your name, address, and contact information. 2. List the items you are seeking reimbursement for. Include the date of purchase, cost, and description of the item. 3. Provide documentation of the purchase. This could include a receipt, invoice, or other proof of purchase. 4. Attach any other relevant information, such as a letter from your doctor or a note from your supervisor. 5. Sign and date the form to certify that the information is accurate. 6. Submit the form to your employer or insurance company for processing.