Health Care Reimbursement Request Form

The fields that are bold are required fields
Name:      
Social Security Number:   --    
Address (Street):      
City, State, Zip Code:      
Email Address:      
Phone Number:   () -    
Group ID:      
Group Name:      

REIMBURSEMENT SUBMISSION REQUIREMENTS

  • List reimbursable expense and attach explanation of benefits or itemized bill.
  • Identify each expense as Medical, Dental, Vision, Hearing, or Other, under Type of Expense.
  • If an expense is covered in part by a health plan the balance may be submitted for reimbursement only after all health plan benefits from all sources have been paid. A copy of the health plan's payment voucher or denial must be submitted with the claim. If no health plan applies write "none" in the Plan payment column.
TYPE OF EXPENSEEXPENSE FORDATES OF SERVICETOTAL BILL (ATTACH COPY)PLAN PAYMENT (ATTACH PAYMENT OR DENIAL)AMOUNT OF REIMBURSEMENT DUE
NAMEFROMTO
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  • I certify that the above listed expenses have been incurred by me or my eligible dependents (as defined by the IRS).
  • I certify that all applicable insurance or other health benefits have been exhausted.
  • I certify that I will not deduct or take as a tax credit on my Federal Income Tax Return these reimbursements.
  • I will assume all responsibility for taxes or penalties arising out of any disallowed deductions.
Type Full Name:      
Date:      
I certify that all the information I provided on this form is accurate and follows the rules set forth in the IRS guidelines.
I Accept
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