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
MI
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: ______________________________________________________
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
F-F10_DCRA_121913