Reimbursement Request

Employee Name:
Employee Address:
E-mail Address:
Employer Name:
 
Date(s) of Service:

thru (optional)
Relationship:
   
Patient Responsibility:
$
To the best of my knowledge and belief, my statements in this Reimbursement Request Form are complete and true. I certify that I or my family member has received the services described above on the dates indicated, that the expenses qualify as valid medical services under the Plan. If the expense is for my spouse or dependent, I certify that the person listed is my spouse or meets the definition of dependent in the plan. I certify that I have not been reimbursed previously for these expenses under the Medical Reimbursement Component Plan. I certify that these expenses have not been reimbursed, and are not reimbursable under the Major Medical Plan or any other health plan, such as my spouse's plan. If the reimbursement is requested for prescribed drugs, I certify that such drugs are not prescribed for cosmetic purposes (hair growth, weight loss, etc.). I understand that the expenses I am reimbursed may not be used to claim any federal income tax deduction or credit. I authorize a deduction in my Medical Reimbursement Account in the amount of the reimbursement.
Dependent Name:
    Age:
Day Care Provider:
Day Care EIN:
Reimbursement Requested:
$
To the best of my knowledge and belief, my statements in this Reimbursement Request Form are complete and true. I have read, understand and make the certifications contained in the Certificate of Qualifying Dependent Care Expenses on this Request form. I understand that these dependent care expenses may not be used to claim any federal income tax deduction or credit (including the dependent care tax credit). I agree to file IRS Form 2441 with my tax return and provide any taxpayer identification number required thereon. I authorize a reduction in my Dependent Care Assistance Account in the amount of the reimbursement. I certify that 1 have not sought reimbursement previously for this same expense.

I have read and agreed to the terms of this reimbursement request.

Employee Signature (typed):
Date Signed:
Additional Instructions:
Attach the corresponding Reimbursement Request form and Receipts: