REQUEST FOR REIMBURSEMENT INSTRUCTIONS

Please complete the Request for Reimbursement Form in its entirety.   Incomplete forms will delay the processing of your request.   Expense's that incur in separate Plan Years must be accompanied by a separate request form.  All expenses must have  INCURRED (date services  provided, not paid) within your Employer's Plan Year and after your effective date in the plan.   Add all receipts and write the amount in the appropriate space.  Copy all smaller receipts onto an 8.5 x 11 sheet of paper for scanning purposes. Do not complete separate forms for each receipt, statements, and/or insurance explanation of benefits, only for separate Plan Years.

If you are requesting reimbursement  under Dependent Care, Unreimbursed Medical or an Health Reimbursement Arrangement, please complete Section A of the Request for Reimbursement form. Requests may be faxed, mail or you may bring them to our office. Checks are processed between 8am-4pm. All mailed requests will be processed the day it is received. Faxes received after 3pm will be processed the following  business day. Click on Direct Deposit for processing information and authorization form.

DEPENDENT CARE (DC):  All DC receipts must have the following information:  Care providers tax identification number or social security number, child(ren) name, date of birth and/or age, amount of expense and date of service, not date paid.  Note:  Book, activity fees and  meals not included in tuition, overnight camp and other incidental fees,  ARE NOT REIMBURSABLE.

UNREIMBURSED MEDICAL (URM):   All URM receipts must have the following information:   A medical provider's name & address, date of service (not date paid), type of service/expense and cost of expense(s).   NOTE:   Statements with a  Balance Forwarded  or Previous Balance does not describe type of services provided and are NOT REIMBURSABLE.

Medical expenses must have patients name.   Prescription drugs must include the name of the drug and RX number on the receipt along with the information indicated above.   

OVER THE COUNTER DRUGS/ITEMS: To claim Over-The-Counter-Drugs, the name of the drug must be pre-printed on a third party receipt along with the date purchased.  The purchase must be to treat a specific illness. (i.e. aspirin for headache).   If the drug item is generic or the receipt abbreviates the drug name,  please spell out the full name of the drug and indicate the specific illness.  If the receipt does not include the name of the drug, a box top may included with the price attached which matches the price on the receipt. Bulk purchases are not allowed.

Over-The-Counter Dietary Supplements/Vitamins, diet foods, toiletries, cosmetics and sundry items  and  cosmetic procedures and/or surgery  ARE NOT REIMBURSABLE expenses.

All documentation must originate from a third party provider

PREMIUM REIMBUREMENTS:  Declaration of coverage from the provider indicating that the policy
is in effect. Proof of payment for the month or months due.  Proof of payment may be a cancelled
check, paid receipt or a copy of bank draft.

To be reimbursed, you must first submit a declaration of coverage from your provider which indicates that the policy is currently in effect.  After each payment you must complete a request for reimbursement form and submit with proof of payment.  i.e. cancelled check, copy of bank draft or a receipt from the carrier

HEALTH REIMBURSEMENT ARRANGEMENT (HRA): If you are claiming expenses under your employers HRA, you must submit a copy of your Explanation of Benefits (EOB) provided by your insurance carrier and complete Section A of the claim form, before reimbursement can be made.  If your plan allows for reimbursement of other items, such as dental or vision, your receipts must be in the form of an (EOB) or contain  the following information: Date of Service, Medical Providers name and address type of service and cost of service.

IMPORTANT: You can only be reimburse for out of pocket expenses once. If your out of pocket expenses have been reimbursed by one type of arrangement (i.e. HRA or HAS) they can not be reimbursed by any other type of arrangement (i.e. URM). Your plan may specify which spending arrangement must pay first.  Please refer to your summary plan description (SPD) for further information.  If you and/or spouse or dependents are covered by an Health Savings Account (HSA), coverage under your (URM) will be restricted to dental, vision and/or preventative care.

Reimbursement will be made once the claim exceeds the $15.00 check minimum.    Final claims less than $15.00 and more than $1.00 will be reimbursed at the end of the plan year.   (Cancelled Checks are not accepted).    Only eligible expenses, not reimbursable by insurance and/or any other third party,  are  reimbursable through URM.

                                                         Request for Reimbursement Form