How to File a Claim

Complete the claim form, listing all amounts claimed for medical reimbursement.
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.
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

"*" indicates required fields

Employee Name*

Email*

Healthcare Expense Reimbursement Claims

Date Expense Incurred	Name of Provider	Description of Services Provided	Person for Whom Expense Incurred	Amount Incurred	Actions

There are no Items.

Total

Amount: $0.00

Related Receipts

Drop files here or

Max. file size: 256 MB.

Employee Statement*

I certify that all expenses submitted with this claim form were incurred while I was covered by the Medical Reimbursement Benefit Plan. I understand that I am solely responsible for the sufficiency, accuracy and veracity of all information relating to this claim. I understand that should the expenses submitted with this claim form subsequently be determined by the IRS to be ineligible for the Plan I may be liable for the payment of all related taxes, including Federal, State or Local Income Tax which relate to such expense.

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