Fillable Form Gc-15 (2-14) - Otc Reimbursement Claim Form printable pdf download

Form Gc-15 (2-14) - Otc Reimbursement Claim Form

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Send completed form and documentation to:

OTC (Over-the-Counter)

Aetna

Reimbursement Claim Form

PO Box 4000

Richmond, KY 40476-4000

Fax to: 1-888-238-3539 (1-888-AET-FLEX)

Preparing Your Claim Form

• Complete all sections below. Include an itemized purchase receipt for each OTC item and Prescription if applicable.

• Retain copies for your files. Claim information cannot be returned.

• Do not highlight the form or enclosed information. Highlighting makes scanned and faxed documents difficult to read.

• As a participant, you have been assigned a unique Identification Number – 9 digits preceded with a “W”. If you do not

know your W#, you can locate it on any of these sources – Explanation of Payment (EOP) or your Aetna Medical ID Card (if

you have Aetna medical coverage); Member Services (call Member Services).

NOTE: If you prefer, you can use your Social Security number in this field.

• We recommend that your Total Amount Submitted be a minimum request of $25.

1. Employee Information

Employee’s Identification Number

Employee’s Last Name

First

Daytime Telephone Number

(

)

Street Address

City

State

ZIP Code

2. Employer Information

Employer Name

Control Number

3. Expense Information

A Prescription is required with each request for reimbursement for OTC medicines. The prescription must include

the patient’s name and be written, signed and dated by the licensed health care professional. Please see below for OTC items that do not

require a prescription.

OTC Product Name

Date of Purchase

Amount Submitted

(e.g.,contact lens solution)

(date each product was purchased)

(amount paid for each product)

Sales Tax (where applicable)

Total Amount Submitted

4. Employee Certification

I certify that the expenses for which I am seeking reimbursement from have been incurred by me, or by an individual who

qualifies as my spouse or my dependent under IRS guidelines. I further certify that these expenses have not been

reimbursed, nor shall reimbursement be sought, from any other health plan coverage, including a Health Savings Account

(HSA). I also certify that I have not, and will not, claim a tax deduction or credit for these expenses on my federal income tax

return, or on my state or local tax returns in violation of state or local law. I agree to submit and retain sufficient

documentation for any expense for which I seek reimbursement.

Any person who knowingly and with intent to defraud files a statement of claim containing any materially false, incomplete or

misleading information is guilty of a crime.

Employee Signature

Date

Sign Here ►

See reverse side for examples of eligible expenses.

GC-15 (2-14) J

R-POD

Form Gc-15 (2-14) - Otc Reimbursement Claim Form

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