Claim Form
E-mail, fax, or mail completed form and itemized verification to third-party administrator. Instructions on reverse. Fillable version at .
VEBA Plan Third-party Administrator
Meritain Health | PO Box 27810 | Minneapolis, MN 55427-0810 | Phone: 1-888-828-4953 | Fax: (763) 582-3470 | E-mail:
1.
1. ParticiPant information
________________________________________________
_____________________________________
_______________________________________
Last Name
First Name
Participant Account No. or SSN
________________________________________________________________________________________
(__________) _________-__________________
E-mail Address (home or personal recommended)
Check here if new e-mail address
Area Code and Phone Number
______________________________________________________________
__________________________________
_________
______________
Mailing Address
Check here if new address
City
State
Zip
2.
2. out-of-Pocket exPenses and Premiums
NOTE: Federal law requires the third-party administrator to have on file the full name, Social Security number, gender, and date of birth of all covered individuals.
Patient (covered individual) information
Relationship to participant
1
Self
Qualifying child
___________________________
_____
___________________________
First Name
M.I.
Last Name
Spouse Qualifying relative
___________________________
_____
___________________________
Other:__________________
Date of Birth (mm/dd/yyyy)
Gender
Social Security Number
Total out-of-pocket
for this covered individual
Expense type(s) [check one, or more if submitting multiple expense types for this covered individual]
Medical co-pay
Medical out-of-pocket
Dental / Ortho
Premium
$
,
.
Medical deductible
Prescription (Rx)
Vision
Other: _____________________
Patient (covered individual) information
Relationship to participant
2
Self
Qualifying child
___________________________
_____
___________________________
First Name
M.I.
Last Name
Spouse Qualifying relative
___________________________
_____
___________________________
Other:__________________
Date of Birth (mm/dd/yyyy)
Gender
Social Security Number
Total out-of-pocket
for this covered individual
Expense type(s) [check one, or more if submitting multiple expense types for this covered individual]
Medical co-pay
Medical out-of-pocket
Dental / Ortho
Premium
$
,
.
Medical deductible
Prescription (Rx)
Vision
Other: _____________________
Patient (covered individual) information
Relationship to participant
3
Self
Qualifying child
___________________________
_____
___________________________
First Name
M.I.
Last Name
Spouse Qualifying relative
___________________________
_____
___________________________
Other:__________________
Date of Birth (mm/dd/yyyy)
Gender
Social Security Number
Total out-of-pocket
for this covered individual
Expense type(s) [check one, or more if submitting multiple expense types for this covered individual]
Medical co-pay
Medical out-of-pocket
Dental / Ortho
Premium
$
,
.
Medical deductible
Prescription (Rx)
Vision
Other: _____________________
NOTE: If your account is allocated among multiple investment funds, withdrawals (claims) will be deducted
GRAND TOTAL
$
,
.
pro rata based on your balance in each fund at the time of withdrawal unless you request otherwise.
for this form
3.
3. ParticiPant signature (required)
I hereby certify that (1) the information provided in this claim request is true and correct; (2) the amount of this submitted claim to the Third-party Administrator is an accurate
statement of my unreimbursed medical/dental/vision expenses and/or medical/dental/vision/tax-qualified long-term care insurance premiums; and (3) the submitted claim is
not reimbursable from any other source. With respect to claims submitted on behalf of qualified dependents, I hereby certify that such person meets the Plan requirements as
summarized on the reverse and is a qualified dependent as defined under the terms of the Plan. With respect to claims for qualified insurance premiums, I hereby certify that such
premiums have not been paid by my employer and are not eligible for pre-tax deduction through my or my spouse’s section 125 cafeteria plan.
Required itemized verification attached (see instructions on reverse)? q Yes
q No
X
____________________________________________________________________________________
_________________________________
Participant Signature
Date
VB01 (06/09)