Dcra Reimbursement Request Form Dependent Daycare Expenses Only printable pdf download

PLEASE MAKE COPIES OF THIS FORM FOR FUTURE CLAIMS

DCRA

REIMBURSEMENT REQUEST FORM

Dependent DayCare Expenses Only

(For Qualifying Dependent Care Reimbursement Account (DCRA) Babysitting Expenses/Elder Daycare Expenses)

NOTE:

This form MUST be completed to receive reimbursement for out-of-pocket Dependent Daycare expenses for your Dependent Daycare

Account(s). These services MUST have been incurred during the current Plan Year. An itemized copy of the provider’s itemized

bill/receipt verifying the name of the care provider, the provider’s Tax ID or Social Security Number and signature, and the

date(s) of service MUST be attached to the back of this form. Your claim will not be processed until these items are received by

MGIS. Credit card receipts cannot be accepted.

FAX COMPLETED FORM AND ALL DOCUMENTATION TO:

MEDICAL GROUP INSURANCE SERVICES, INC.

CLAIMS FAX: 877.760.7081

PLEASE COMPLETE ENTIRE FORM. PRINT OR TYPE. (USE ADDITIONAL SHEETS IF NECESSARY.)

EMPLOYER NAME:

PLAN YEAR:

EMPLOYEE NAME: _______________________________________________________

SOCIAL SECURITY NUMBER: _______-______-_______

LAST

FIRST

EMPLOYEE HOME ADDRESS: ________________________________________________

_________________________

_____

_______________

NUMBER AND STREET

CITY

STATE

ZIP

 CHECK HERE IF THIS IS A CHANGE IN ADDRESS

EMPLOYEE DAY PHONE: (

)

EMPLOYEE E-MAIL:

UNREIMBURSED DAYCARE EXPENSES

(QUALIFYING BABYSITTING EXPENSES/ELDER DAYCARE EXPENSES)

See IRC Section 129 for qualifying Dependent Care expenses or consult your tax advisor for more information.

COVERED PERIOD

PERSON WHO

AGE AT TIME

DATE OF BIRTH

CARE PROVIDER NAME

AMOUNT

RECEIVED CARE

OF SERVICE

START DATE

END DATE

Credit card receipts or cancelled checks cannot be accepted.

TOTAL UNREIMBURSED DCA CLAIMS

CARE PROVIDER INFORMATION

THIS SECTION MUST BE COMPLETED FOR REIMBURSEMENT

BABYSITTER INFORMATION

DAYCARE CENTER INFORMATION

NAME: _________________________________________________________

DAYCARE CENTER NAME: ________________________________________

ADDRESS: ______________________________________________________

_______________________________________________________________

________________________________________________________________

SOCIAL SECURITY #: _____________________________________________

TAX ID# _________________________________________________________

_______________________________________________________________

________________________________________________________________

DAYCARE PROVIDER’S SIGNATURE (REQUIRED)

To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true. I understand that I am solely responsible for the validity of claims

submitted to my Dependent Care Assistance Plan Account. I am claiming reimbursement only for eligible expenses incurred by myself for my spouse and/or covered dependents (for

DCA reimbursement, these expenses must have been incurred during the Plan Year shown above) and certify that these expenses have not been reimbursed under this Plan or by

any other source and that they will not be reimbursed by any other source or insurance. I hereby authorize my Dependent Care Account to be reduced by the amount(s) shown above.

X ____________________________________________

PARTICIPANT’S SIGNATURE

DATE ____________________________

If you have questions or need assistance, call the number listed below or visit our website.

Medical Group Insurance Services, Inc. • 1849 W North Temple • Salt Lake City, Utah 84116 • 1.866.937.3539 • Claims Fax 877.760.7081

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