Medical Expense Claim Form

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City of Stamford Medical Expense Claim Form
Mail Claim Form to:
City of Stamford Flexible Reimbursement Program
PO BOX 5817
Wallingford, CT 06492
Tel: (800) 446-8646
Social Security No.: ___________ - ____________ - ____________
Participant’s Name: ____________________________________________________________________________________________________________
Last
First
Middle
The undersigned Participant in the Plan requests reimbursement in the amounts shown below:
Date
Name of Service
Describe
Person for Whom
Net
Incurred
Provider
Expense
Expense Incurred
Amount
______________
_______________________
_________________________
__________________________
$______________
______________
_______________________
_________________________
__________________________
$______________
______________
_______________________
_________________________
__________________________
$______________
______________
_______________________
_________________________
__________________________
$______________
______________
_______________________
_________________________
__________________________
$______________
Total Amount of Medical Expense $_____________
Note: Federal law requires that you submit a written statement (such as an itemized bill from the service
provider – or an Explanation of Benefits from your insurance carrier which would show the amount
billed by your provider and the amount paid (or not paid) by your insurance company) as proof that the
claim is not being reimbursed by an Insurance Company. Also, you will not be entitled to claim this
expense as a tax deduction.
The undersigned Participant in the Plan certifies that all expenses, for which reimbursement or payment
is claimed by submission of this form, were incurred during a period while the undersigned was covered
under the Tax Savings Plan with respect to such expenses and that such expenses have not been
reimbursed, or are not reimbursable, under the health plan coverage. The undersigned fully understands
that he or she alone is fully responsible for the sufficiency, accuracy and veracity of all information
relating to this claim which is provided by the undersigned, and that unless an expense for which
payment or reimbursement is claimed is a proper expense under the Plan, and the undersigned may be
liable for the payment of all related taxes including federal, state or city income tax on amounts paid from
the plan which relate to such expense.
__________________________________________________________
___________________________________
Employee Signature
Date

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