Medical Reimbursement Form

VANPOOL DRIVER/BACKUP DRIVER MEDICAL EXAMINATION REIMBURSEMENT REQUEST

Click here for a printable PDF version of the Medical Reimbursement Form

Return completed request to: Dibs, 555 East Weber Ave., Stockton, CA 95202; 1-800-527-4273; fax: 209-235-0601












All personal information is kept private and is not shared with other agencies or businesses.



PLEASE SUBMIT THIS INFORMATION WITHIN THREE MONTHS OF EXAMINATION DATE

I certify that I or my vanpool coordinator has paid for a DOT Medical Examination to qualify me as a Vanpool Driver according to the State of California Vehicle Code Statutes. I have attached the following as verification (both items must be included):


  1. ORIGINAL receipt showing the amount you paid for examination, and
  2. Photocopy of Medical Examiner’s Certificate signed by the examining physician
    (NOT the Medical Examination Report)