Claim Forms

Please note that a claims processing fee will be assessed for each claim submitted whether your account is eligible for reimbursement or has a sufficient balance to pay the claim. Therefore, you should verify your Claims Reimbursement Status prior to submitting your claim.

Evidence of expense must be submitted for all claims. The only documentation necessary for most claims is the Explanation of Benefits (EOB) which is issued by your insurance company. Please review the instructions on the claim form for more details.

Form	Usage	Expenses Incurred in Year
Medical Expense Reimbursement Claim Form	This form may be used for: Medical & Dental Expenses Copayments & Deductibles Prescriptions	2024 2023
Medical Insurance Claim Form	This form may be used for: Medical Insurance Premiums Dental Insurance Premiums Vision Insurance Premiums	2024 2023
Disability Insurance Claim Form	This form may be used for: Disability Insurance Premiums	2024 2023
Dependent Care Assistance Claim Form	This form may be used for: Dependent Care (Child Care) Expenses Please note a Dependent Care Assistance Certification Form must be submitted each year you submit Dependent Care Assistance Claim Forms. If your Dependent Care Provider does not have formal receipts you may use our Dependent Care Receipt	2024 2023
Direct Payment Claim Form	This form may be used to authorize a direct payment to: Doctor Hospital Service Provider Please note that services must be rendered prior to requesting reimbursement. Only one service provider may be listed on each claim form.	2024 2023

If you have a spouse, over age dependent or you wish to authorize another person to inquire about:

Reimbursement Claims Information
Insurance Coverage Information
Any other protected medical information

Please complete and sign the Health Information Disclosure Authorization Form or the Durable Power of Attorney and Health Information Disclosure Authorization Form below. You may return the form via fax or mail.

Health Information Disclosure Authorization Form Only

This form will authorize our Member Services Department to speak with your spouse or other authorized person regarding Reimbursement Claims and/or Eligibility Information for your account. If this form is not on file, the Flex Plan can only provide this account information to the member; your spouse or authorized person will only be provided with general non-account specific information.

Form

Durable Power of Attorney and Health Information Disclosure Authorization Form

This form will allow your “Authorized Representative” to obtain information regarding Reimbursement Claims and/or Eligibility Information for your account. In addition, it grants to your Authorized Representative the ability to submit claims, to have access to all Plan Information about your claims and eligibility, and change insurance elections. In the event the member is not able to perform these duties their Authorized Representative will be able to do so on their behalf.

Form