Business Expense/Travel Reimbursement
  • SEND COMPLETED FORM TO: ACCOUNTS PAYABLE VIA INTEROFFICE MAIL, 555 SOUTH BROADWAY BLDG B 2ND FL, TARRYTOWN NY 10591
  • REFER TO EMPLOYEE REIMBURSEMNT POLICY JP06.1
  • The expense being claimed for reimbursement must be reasonable, directly connected with, and necessary or appropriate in pursuit of the Montefiore Business. An original receipt must support each expense regardless of dollar amount.
  • All checks for reimbursement will be mailed directly to the employee’s home.
  • In the case of a Clinical Department Chairman, the Vice-Chairman or Department Head & Vice President can approve employee business expense reimbursements up to $750. An Executive Vice President must approve expense reports that exceed $750.
  • For CME programs, the Director of CME and/or Director of Research and Sponsored Programs must approve all expenses.

  • EMPLOYEE MUST SIGN REIMBURSEMENT
    • All Employee Reimbursement requires two signatures. One is the employee signature the other is the employee’s direct report, excluding reimbursement to Chairman’s.
    • The employee’s direct report (manager, supervisor, etc) must approve the Employee Reimbursement request form.
    • In the case of a Clinical Department Chairman, the Vice-Chairman or Department Head & Vice President can approve employee business expense reimbursements up to $750. An Executive Vice President must approve expense reports that exceed $750.
    • A stamped imprint of an authorized signature is not acceptable.
  • All expenses should be entered by Month.
    • If there are multiple receipts for the month, enter business purpose next to each receipt as well as explanation of Business Purpose
DATE PREPARED*
COMPANY CODE*
EMPLOYEE NAME*
EMPLOYEE HOME ADDRESS*
APT #
CITY*
STATE*
ZIP CODE*
MONTEFIORE DEPARTMENT*
TELEPHONE*
Employee ID#*

THIS FORM MUST BE COMPLETED IN ACCORDANCE WITH THE RELATED MONTEFIORE POLICY. ALL CHECKS WILL BE MAILED DIRECTLY TO THE EMPLOYEE'S HOME ADDRESS.
NATURE OF EXPENSE DATE 1
DATE 2
DATE 3
DATE 4
DATE 5
COMPANY CODE ACCOUNT G/L # COST CTR./ORDER # TOTALS
LODGING (EXCLUDING MEALS)
MEALS
AUTO MILEAGE
AIRFARE (NOT PAID DIRECTLY BY MONTEFIORE)
PARKING AND TOLLS
CAR RENTAL
TAXI, BUS, TRAIN
OTHER
OTHER
TOTAL FOR THE DAY ISSUE CHECK
EXPLANATION OF BUSINESS PURPOSE:
(1)
(2)
(3)
(4)
(5)



DEPARTMENT PERSON TO CONTACT FOR QUESTIONS.
NAME
TELEPHONE
DEPARTMENT
LOCATION