Fill and Sign the Reimbursement Fo Reimbursement Form Medical Expenses

Medical Care Reimbursement Request -- Flexible Benefits Plan Employee’s Name __________________________________ SSN _________________ Last First MI Employer ______________________________________ Employee ID (if known) ___________ Home Address ______________________________________________________________ Street City State Zip Home Phone (_____)___________________ Work Phone (____)_____________________ Please list all out-of-pocket unreimbursed eligible medical expenses, as defined in the Summary Plan Description (SPD), for which you are requesting reimbursement. Description of Expense Date of Service Amount 1 ______________________________________ ___________________ ___________ ______________________________________ ___________________ ___________ ______________________________________ ___________________ ___________ ______________________________________ ___________________ ___________ ______________________________________ ___________________ ___________ ______________________________________ ___________________
? 1(a) 1(b) 1(c)   (b) if the amount is less than 25, your employer's employer contribution for covered medical care of an eligible employee and of up to 1,000 of out-of-pocket expenses incurred by the employee, for a covered health plan year in which you are receiving payments from that plan, shall not exceed 50% of the eligible employee's out-of-pocket expenses (100), if the out-of-pocket expenses are incurred for: (a) the same, or substantially similar, medical services (determined without regard to whether the same medical services were performed in the same or in different locations) or hospitalizations (determined without regard to whether the same hospitalizations were performed on the same or different days); (b) the same, or substantially similar, prescription drugs; (c) the same, or substantially similar, physician services unless the services would not have been required to be had the same services been required for any other employee, including the spouse, of the employee; or (d) the same, or substantially similar, other medical care services. Your employer's employer contribution for covered medical care of an eligible employee and of up to 1,000 of out-of-pocket expenses incurred by an eligible employee for the same, or substantially similar, medically necessary services or hospitalizations and related out-of-pocket costs for the other, qualified patient(s) shall not exceed 50% of the total eligible patient(s) covered under the plan. (e) an eligible employee must be enrolled and receive medical care from a health professional in-network within 30 days after the date the employee requires medical care for illness or injury. If an eligible employee is not in-network within 30 days after the date an eligible individual requires in-network health care for medical needs, the eligible employee must be referred to in-network health care or the employee's medical account shall be credited a percentage of the full cost of the in-network care as determined in accordance with the following table: health care coverage or treatment provider (% of coverage) out-of-network cost percentage 1 physician 2 physician 3 physician