Claim Appeals Form
Parent /.Guardian Name
First Name
Last Name
Email
Please enter the email address of the parent or guardian associated with Merit.
Student Name
First Name
Last Name
Claim Amount
Please enter the exact amount submitted in the claim in question.
Service Provider
Which organization or business did you purchase a service or hard good from?
Please enter the claim number and tell us why your claim should have been approved for reimbursement.
*
Please include as much information as possible. If you are unsure of the claim number (found in the rejection notification email), we will make best efforts to identify the claim based on the information provided above.
Submit
Should be Empty: