Reimbursement Request Form

Reimbursement Request

This form provides another way to submit your reimbursement requests and related documentation.

Your Name*
Your Email*
Are you faculty or non-faculty?
- Faculty
- Non-Faculty
Is the reimbursement urgent or non-urgent?
- Urgent
- Non-Urgent (submitted within 6 weeks)
Is this reimbursement travel-related?*
- Yes
- No
Location*
***City and state, or city and country if international***
Business Purpose*
Please provide a brief description of your expenses and their purpose. This should include what you paid for versus what was prepaid (e.g. with a lab P-Card). Please include enough detail to allow BMC staff to answer Who, What, Where, When, and Why when preparing your reimbursement.*
Please provide a brief description of your expenses and their purpose. This should include what you paid for versus what was prepaid (e.g. with a lab P-Card). Please include enough detail to allow BMC staff to answer Who, What, Where, When, and Why when preparing your reimbursement.
Please provide conference link or enter N/A*
Please provide a detailed benefit for UW Madison to justification this reimbursement (Required by SMPH Fiscal).*
Example: Dr. XXXX attended the 27th Annual Spring conference on XXXXXX in XXXX, April 12-15, 2023. This benefits the University of Wisconsin as Dr. XXX gained valuable information and tips regarding care of ill patients that she can apply to both her general pediatric and urgent care jobs, to improve patient Care. In particular, Dr. XXX learned more about caring for babies with fever and sepsis, how to differentiate different important rashes, how to identify significant injuries in baseball players and how to manage foreign bodies in different locations. There was also information and updates for the ongoing care of patients with mental health issues. This knowledge will be shared with faculty colleagues and students that Dr. XXXX teaches.
Start Date*
For travel-related requests, this is the departure date. For non-travel requests, this is the date of your earliest expense.
MM slash DD slash YYYY
End Date*
For travel-related requests, this is your return date. For non-travel requests, it is the date of your latest expense.
MM slash DD slash YYYY
Funding Information*
PLEASE PROVIDE THE PROJECT NUMBER(S) (format AAA1111) from which this reimbursement is to be paid. If expenses should be split, please indicate percentages or specific costs next to each project.
Receipt Upload*
Please attach all receipts here. You may scan receipts or take pictures with a smartphone or other device, but please be sure the images are clear.
Drop files here or

Max. file size: 24 MB.
Supplementary Forms
If you need to provide additional forms (e.g. you hosted a meal, need to submit a list of event participants, etc.), please upload them here. Several common forms are linked on this page (they can be found at the top of this form on most computers and below the form on mobile devices).
Drop files here or

Max. file size: 24 MB.
Prepaid Expenses
If you have any prepaid expenses related to a travel reimbursement (e.g. flights, conference registration), please upload receipts here. Even if reimbursement for these expenses is not requested here, receipts should be included.
Drop files here or

Max. file size: 24 MB.
Notes
If you have any other notes you would like to provide on this request, please add them here.
For all urgent faculty reimbursements, please follow the link below.
How to Create, Modify and Resubmit an Expense Reimbursement in eReimbursement
Name
This field is for validation purposes and should be left unchanged.

Supplementary Forms (Often Required)

Accountable Plan Exception Request
This form must be submitted with any reimbursement requests older than 90 days. Reimbursements issued outside this period are considered taxable income.
Event Meal Payment Form
If you hosted a meal, please complete and attach this form to your reimbursement request.
Events Refreshment Payment Form
This form should be submitted with requests for reimbursements tied to refreshment breaks during lengthier events.
Participant List
For many events (e.g. hosted meals, receptions, etc.), a list of participants is required with your reimbursement request.

Useful Links

Lodging Maxima and Per Diem Calculator

Vehicle Use/Rental Policy

Reimbursement Request

For all urgent faculty reimbursements, please follow the link below.

Supplementary Forms (Often Required)

Useful Links