How to File a Claim

  1. Complete the claim form, listing all amounts claimed for medical reimbursement.
  2. Make sure the claim does not include items for more than one Plan Year. Please use separate claim forms for items incurred in different Plan Years.
  3. Consult with your Plan Administrator for policies on handling bills, invoices, canceled checks, or other supporting documents.

IT IS YOUR RESPONSIBILITY TO PROVIDE SUPPORT FOR THIS CLAIM IN THE EVENT OF AN IRS AUDIT.

Reimbursement Form

Date Expense Incurred Name of Provider Description of Services Provided Person for Whom Expense Incurred Amount Incurred Actions
         
Amount: $0.00
Drop files here or
Max. file size: 256 MB.
    Employee Statement*

    This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.