Health Professions
Scholarship Program (HPSP)
How To Submit A Reimbursement
Army
Steps for completing reimbursement
• Print off the Medcom Form 678-R found at
http://www.atsu.edu/registrar/military.htm
• Fill in the top section with the student and
institution information
• If claiming Health Insurance, Vaccinations,
USMLE fees, and Eras Fees complete Item 12
with dates claimed and cost
• Enter total
Army
Steps for completing reimbursement
• Enter Required Textbooks/ Author, Equipment
and Supplies in Item 13
• Enter Date of Purchase and Cost in appropriate
columns
• Add up sales tax and enter on Total Taxes for
Item 13 Line
• Add total of books to sales tax and enter in the
Total column for Item 13
• Enter Grand Total Items for 12 and 13
• Sign the form
Army
Steps for completing reimbursement
• Attach your receipts or copies of receipts to your claim. If
using small receipts from the bookstore please tape
them to a blank sheet of white paper. You do not need
to include the actual credit card processing receipt.
• Attach the required book list to your claim. The required book
list will be available on the Registrar’s webpage after the
beginning of each quarter. This book list is not to be used as a
shopping list but is needed with submission of your claim.
• Deliver, mail, or fax to the Record’s Coordinator in the
Registrar’s Office.
• We will check forms to make sure it contains only
reimbursable items, sign and forward to the Army for
reimbursement.
• Please make copies of all forms and receipts for your records.
Navy
Steps for completing reimbursement
• Print off the Dean’s Certificate and Standard Form 1164 found
at http://www.atsu.edu/registrar/military.htm
• Complete student and university information at the top of the
Dean’s Certificate. We will complete the rest of that form.
• On Standard Form 1164, complete the top portion for the
Claimant information
• Enter all expenditures in the expenditure portion of the form.
Enter date (A), items you are claiming in the C and D columns
and enter the cost in the Mileage (F) column.
• If needed, continue on back of form and carry totals over to
the front in the Subtotals Carried Forward from the Back
column.
Navy
Steps for completing reimbursement
• Enter sales tax and label it on one of the lines.
• Enter total amount claimed on line 7 Amount
Claimed.
• Sign and date the form in section 10.
Navy
Steps for completing reimbursement
• Attach your receipts or copies of receipts to your claim. If
using small receipts from the bookstore please tape
them to a blank sheet of white paper. You do not need
to include the actual credit card processing receipt.
• Attach the required book list to your claim. The required book
list will be available on the Registrar’s webpage after the
beginning of each quarter. This book list is not to be used as a
shopping list but is needed with submission of your claim.
• Deliver, mail, or fax to Record’s Coordinator in the Registrar’s
Office.
• We will check forms to make sure it contains only
reimbursable items, sign and forward to the Navy for
reimbursement.
• Please make copies of all forms and receipts for your records.
Air Force
Steps for completing reimbursement
• Print off the AFIT Form 31 found at
http://www.atsu.edu/registrar/military.htm
• Complete form and forward to the Air Force. Air
Force students do not turn anything into the
Registrar’s Office and their forms do not require
the Registrar’s signature (Navy & Army do).
• The required book list for each quarter,
insurance is required letter and required supply
list will be available on the Registrar’s webpage
after the start of each quarter.
Please remember the following tips:
• Please submit health insurance for
reimbursement each time the premium is
paid.
• Only items for reimbursement should be
included on receipts submitted with
reimbursement form. Purchase other nonreimbursable items in a separate
transaction.
• Forms can be found at
http://www.atsu.edu/registrar/military.htm
KCOM SAMOPS LIAISONS
• Army- Stephanie Sutthoff
• Navy- Ed Weimholt
• Air Force- Brittaini McGinnis