Medical Payments and Reimbursements Form

Please make sure that medical bills are sent to insurance first. Once insurance adjustments are reflected on the bill, please submit it to American Councils.

AC reimburses or pays directly for copay's and medical expenses required to attend school that were denied by insurance. American Councils cannot reimburse medical expenses other than copays until they have gone through insurance.
Physicals required for participation in extracurricular sports should be paid out of the student’s Incidentals allowance.
Receipts or invoices must be submitted with this form.

Please allow 3-4 weeks to receive a reimbursement. Reimbursements may be made by check or ACH (electronic bank transfer). If you are interested in ACH reimbursement, we will need to request some information from you. Please contact the International Student Support Team at inbound@americancouncils.org with questions.

Student First Name

Student Last Name

Program

FLEXYESUUTI

Host Family

Local Coordinator

Name of person to be reimbursed

Select one of the following

Specify what needs to be reimbursed to you and what needs to be paid by us if not clear in invoice/receipt attached.

Preferred Payment Method:

ACH/Electronic Transfer
CheckStudent Bank Card (students only)

Have you received an ACH/Electronic Transfer from us in the past?

YESNO

Has your banking information changed?

YESNO

Payment Information

If you are requesting an ACH/Electronic Transfer for your reimbursement, please fill out form linked here and upload it below. If you do not submit the form with all information, your reimbursement will be processed with a check.

Click Here for the fillable ACH Request Form.

Information on this form is treated as sensitive data and will not be shared outside of this organization.

ACH Information

If multiple submissions, click bottom right corner of Medical Expenses section "Add another expense." No limit.

Medical Expenses