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HEALTH EXPENSES REIMBURSEMENT FORM


IDENTIFICATION

Employee Name:
Phone:

Social Security Number:
Date:

Employee Number:
Email:

Position/Title:
Dept:



MEDICAL EXPENSES

Date of Service     Physician or other Provider             Amount
                                                                                                          
          TOTAL MEDICAL EXPENSES TO BE REIMBURSED     

I have HEALTH insurance:  ( Yes ( No     DENTAL insurance: (Yes  ( No         VISION Insurance: (Yes  ( No


DEPENDENT/CHILD CARE EXPENSES

Name of Dependent Care Provider:          Providers Taxpayer ID#     

Address of Provider:                       

Name of Dependent(s):                       

Services   From:        To:          Amount:         From:        To:          Amount:         From:        To:          Amount:     

        TOTAL DEPENDENT EXPENSES TO BE REIMBURSED     

Signature of Care Provider                Date:      


I certify that the statement and information on this reimbursement form are accurate and true. I also certify that I am claiming reimbursement for only eligible expenses incurred during the plan year and only for eligible plan participants. I certify that these expenses have not been or will not be reimbursed under this or any other benefit plan. I further certify I will not claim these, or any other expenses reimbursed through this plan, as an income tax deduction and I assume all liability for taxes and penalties out of any disallowed deduction/credit.

Employee Signature:                  Date:      

*If you DO NOT have a receipt your claim will not be reimbursed unless your daycare provider has signed this form.


FOR ADMINISTRATIVE USE ONLY

Reviewed By:       Date:                 Plan Year:      Approved: $             Denied: $  

Reason for Denial:            Action:           
INSTRUCTIONS FOR MEDICAL AND DEPENDENT CARE REIMBURSEMENT ACCOUNTS


Only employees participating in the plan can submit a reimbursement form; employees may be reimbursed from the plan at any time during the plan year.

Reimbursements may only be made for eligible expenses incurred during the plan year.

Complete the information on the reimbursement form for each amount claimed.

If you receive reimbursement for expenses, you may not claim these expenses for income tax purposes.

You must sign the form, thereby swearing that you have not and will not submit these expenses for reimbursement from another plan.



MEDICAL REIMBURSEMENT ACCOUNT

Documentation must be invoices or other written statements from the third parties that provided the services.

The documentation must show the providers name and address, the dates the services were provided, the amounts charged for the services, and a brief description of the services.

For services that you have insurance coverage, you MUST submit the Explanation of Benefits from your insurance company.

In general, the types of expenses for medical services that can be reimbursed by the Plan are the same types of expenses that the Internal Revenue Service would allow for the health expense deduction under Internal Revenue Code Section 213. Further information can be found by obtaining IRS Publication 502 by calling 1-800-829-3676.



DEPENDENT CARE REIMBUSEMENT ACCOUNT

You may have your provider sign the claim form in the appropriate place or attach a separate receipt from you provider.

You must show the name, address, and tax identification number of the provider, the dates the services were provided and the amounts charged for the services.

If your expenses qualify for reimbursement from the Plan, you will be reimbursed for the total of your expenses, but not more than your account balance in the Plan. Your account balance is the total of the deposits youve made into your Dependent Care Flexible Spending Account minus the reimbursements youve received.

In general, the types of expenses for dependent care services which can be reimbursed by the Plan are the same type of expenses which the Internal Revenue Service would consider for the dependent care tax credit as employment-related expenses under Internal Revenue Service Code Section 21(b)(2). Further information can be found by obtaining IRS Publication 503 by calling 1-800-829-3676.

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