Money in your pocket
DENTAL and MEDICAL EXPENSES:
For each expense listed that is or may be covered under an insurance plan, submit your bills to the insurance company(ies) and then submit the insurance company statement of benefits
showing the amount of expenses not covered by insurance with this form.
For other expenses attach an itemized statement.
For prescription drugs, attach the pharmacy statement or label. Keep a copy of all documentation for your records.
For covered over-the-counter (OTC) items, a cash register tape with the name of the drug imprinted by the store register is required. OTC drugs, medicines and biologicals are eligible only if accompanies with a letter of medical necessity from a medical provider. Such items cannot be purchased by the debit card program, but can be reimbursed by filing a paper claim with all require documentation.
DEPENDENT CARE EXPENSES:
For each dependent care expense listed,
attach a third party statement
complete the Dependent Care Provider Acknowledgement,
provider signature is required. The qualified dependent who spends at least eight hours a day in your home must be age 12 or under; or any other qualified dependent person, who is physically or mentally incapable of self-care (such as a disabled parent or older child) regardless of age. A doctor’s statement of disability is required. Qualified expenses are for care only. Educational expenses, registration and activity fees are not reimbursable.