Emeriti Qualified Medical Expense Claim Form Page 2

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3.   L ist   o f   Q ualified   M edical   E xpenses.     E nter   e ach   Q ME   c laim   i n   t he   c hart   b elow.     I f   a dditional   s pace   i s   n eeded,   p lease   p rovide   a ll   r equested   i nformation   f rom  
the   g rid   b elow   o n   a   s eparate   s heet   o f   p aper.  
Service/Product   R ecipient   ( i.e.   P atient)  
 
 
 
 
Service/Product    
Provider's   N ame  
Requested  
Date   o f  
Relationship   t o   P articipant*  
  ( e.g.   D octor,  
Type   o f   E xpense  
Reimbursement  
Service/Purchase  
Name  
SSN  
  ( must   c heck   o ne   b ox)  
Date   o f   B irth  
Pharmacy,   C linic)  
(must   c heck   o ne   b ox)  
Amount  
o
Rx   D rugs  
o
Myself  
o
Medical   C are  
o
Spouse  
o
Dental   C are  
o
Dependent   C hild  
o
Vision   C are  
o
Dependent   D omestic   P artner    
o
Insurance   P remium  
o
Non-­‐Dependent   D omestic  
o
Other  
Partner**  
 
o
Dependent   R elative  
Set   u p   a s  
o
 
o
Surviving   S pouse  
recurring  
 
o
Surviving   C hild  
claim
 
   
   
   
   
 
   
o
Myself  
o
Rx   D rugs  
o
Spouse  
o
Medical   C are  
o
Dependent   C hild  
o
Dental   C are  
o
Dependent   D omestic   P artner    
o
Vision   C are  
o
Non-­‐Dependent   D omestic  
o
Insurance   P remium  
Partner**  
o
Other  
o
Dependent   R elative  
S et   u p   a s  
 
 
o
o
Surviving   S pouse  
recurring  
 
o
Surviving   C hild  
claim
 
   
   
   
   
 
   
o
Myself  
o
Rx   D rugs  
o
Spouse  
o
Medical   C are  
o
Dependent   C hild  
o
Dental   C are  
o
Dependent   D omestic   P artner    
o
Vision   C are  
o
Non-­‐Dependent   D omestic  
o
Insurance   P remium  
Partner**  
o
Other  
o
Dependent   R elative  
 
S et   u p   a s  
o
 
o
Surviving   S pouse  
 
recurring  
o
Surviving   C hild  
 
claim
 
   
   
   
   
   
*     P lease   r efer   t o   t he   s eparate   F requently   A sked   Q uestions   d ocument   r egarding   w ho   q ualifies   a s   a n   e ligible   “ Plan   D ependent.”  
 
**   P lease   n ote   t hat   r eimbursed   c laims   f or   n on-­‐dependent   d omestic   p artners   a re   t axable   d istributions   f rom   t he   P lan.     P lease   r efer   t o   F requently   A sked   Q uestions   f or   d etails.    
2
 
 
 
 
 
 

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