Emeriti Qualified Medical Expense Claim Form printable pdf download

E meriti R etirement H ealth S olutions

Qualified M edical E xpense C laim F orm

Please u se t his C laim F orm t o s ubmit c laims f or t he r eimbursement o f Q ualified M edical E xpenses, o therwise

known a s t he E meriti R eimbursement B enefit, u nder y our ( former) e mployer’s E meriti R etiree H ealth P lan

(“Plan”). B efore y ou c omplete a nd s ubmit t his C laim F orm, p lease r ead t he a ccompanying d ocument e ntitled

Frequently A sked Q uestions c arefully. B e s ure t o p rovide a ll r equested i nformation, s ubstantiate y our

claim(s) b y p roviding p roof o f p ayment, a nd s ign t he f orm. I f y our c laim i s d enied, y ou w ill b e i nformed b y

mail. Y ou w ill b e p rovided t he r eason f or a d enial a nd a n o pportunity t o a ppeal o r r esubmit y our c laim.

REIMBURSEMENT BENEFIT CLAIM FORM

EMERITI R EIMBURSEMENT B ENEFIT -‐ C LAIM F ORM F OR Q MEs

1. Participant ( Account H older) I nformation:

Name: _ _______________________________________________________________________________________

Institution:_____________________________________________________________________________________

Social S ecurity N umber: _ ______-‐_____-‐_________

S treet A ddress: _ ________________________________________________________________________________

City: _ _______________

State: _ ___

Zip: _ _______-‐_____

Daytime P hone: _ ___-‐___-‐_____

Ext: _ _______

2. Participant E ligibility:

I a m e ligible t o r eceive r eimbursement b enefits b ecause ( check o ne b ox o nly):

o I h ave a ttained a ge 5 5 a nd n o l onger w ork f or t he e mployer s ponsoring t he P lan

o I a m u nder a ge 5 5 a nd n o l onger w ork f or t he e mployer s ponsoring t he P lan ( up t o $ 5,000 i n c umulative

QMEs a re a vailable)

o I a m u nder a ge 5 5 a nd n o l onger w ork f or t he e mployer s ponsoring t he P lan b ut q ualify u nder t he t erminal

illness o r i njury o r e xtraordinary m edical e xpense p rovision

Version 0 325-‐2014

Emeriti Qualified Medical Expense Claim Form