Emeriti Qualified Medical Expense Claim Form (Page 3 of 4) in pdf

4. P roof o f P ayment: Y ou m ust s ubmit p roof o f p ayment f or e ach Q ualified M edical E xpense, w hich m ay b e ( i) a n R x

label, ( ii) a n i nsurance b illing s tatement, ( iii) a n E xplanation o f B enefits ( EOB), o r ( iv) a n i temized b ill f or m edical s ervices

rendered. P lease r efer t o t he I nstructions a nd A dditional I nformation b elow f or d etails.

5. C ertification a nd S ignature: B y m y s ignature b elow I h ereby c ertify a nd/or a cknowledge t he f ollowing:

1) The Q ualified M edical E xpenses i dentified a bove w ere i ncurred b y m e a nd/or m y e ligible P lan D ependent(s). A ny

prescribed m edication o r a llowable m edical s upply r equested a bove w as p urchased f or m e a nd/or m y e ligible P lan

Dependent(s) a nd w as n ot p urchased f or g eneral g ood h ealth.

2) I a m s olely r esponsible f or t he c orrect d esignation o f m y e ligible P lan D ependents, a nd I h ave m ade s uch d esignation(s)

herein i n c ompliance w ith t he t erms o f m y P lan a nd t he S ummary P lan D escription. I u nderstand t hat i f I m ake s uch

designation i ncorrectly, e ither b y e rror o r i ntent, t hat I w ill b e r esponsible f or r efunding t o t he P lan a ny a ssociated i neligible

QME r eimbursements I r eceived a s s oon a s p racticable f ollowing t he d iscovery o f s uch i ncorrect d esignation o f a P lan

Dependent.

3) To t he e xtent I a m s ubmitting a r equest f or t he r eimbursement o f a n e xpense i ncurred b y m y d ependent d omestic p artner,

as i ndicated b y m e i n S ection 3 a bove, I c ertify t hat s uch i ndividual m aintains r esidence i n m y h ome a s h is o r h er p rincipal

place o f a bode a nd i s a m ember o f m y h ousehold. F urther, I c ertify t hat s uch i ndividual r eceives o ver h alf o f h is o r h er

support f rom m e, a nd i s c overed u nder t he t erms o f m y P lan.

4) To t he e xtent I a m s ubmitting a r equest f or t he r eimbursement o f a n e xpense i ncurred b y m y n on-‐dependent d omestic

partner, a s i ndicated b y m e i n S ection 3 a bove, I c ertify t hat s uch i ndividual m aintains r esidence i n m y h ome a s h is o r h er

principal p lace o f a bode a nd i s a m ember o f m y h ousehold, a nd i s c overed u nder t he t erms o f m y P lan.

5) To t he e xtent I a m s ubmitting a r equest f or t he r eimbursement o f a n e xpense i ncurred b y a d ependent r elative, a s i ndicated

by m e i n S ection 3 a bove, I c ertify t hat s uch i ndividual ( a) r eceives o ver h alf o f h is o r h er s upport f rom m e, a nd ( b) i s e ither

(i) m y c hild o r a d escendant o f a c hild, s ibling, s tepsibling, p arent, a ncestor o f m y p arent, s tepparent, a unt, u ncle, n iece,

nephew, s on-‐in-‐law, d aughter-‐in-‐law, f ather-‐in-‐law, m other-‐in-‐law, b rother-‐in-‐law, s ister-‐in-‐law, i rrespective o f w hether

living i n m y h ome, o r ( ii) a nd i ndividual w ho m aintains r esidence i n m y h ome a s h is o r h er p rincipal p lace o f a bode a nd i s a

member o f m y h ousehold, a nd i s c overed u nder t he t erms o f m y P lan.

6) If I r eceive a r eimbursement b enefit f or a c laim i ncurred b y a P lan D ependent w ho i s n ot e ligible t o b e t reated a s m y

dependent u nder t he I nternal R evenue C ode ( such a s a n on-‐dependent d omestic p artner), I u nderstand t hat s uch

reimbursement w ill b e t axable u nder t he I nternal R evenue C ode.

7) These e xpenses f or w hich I a m s eeking r eimbursement h ave n ot p reviously b een r eimbursed t o m e ( or a P lan D ependent) b y

any o ther p lan c overing h ealth b enefits, n or w ill I ( or a P lan D ependent) s eek s uch r eimbursement.

8) I a m n ot c urrently c overed u nder a F lexible S pending A rrangement ( a “ FSA”) u nder I nternal R evenue C ode S ection 1 25 ( a

“cafeteria p lan”), o r i f I a m c overed u nder a F SA f or t he a pplicable p eriod, I h ave e xhausted m y m aximum a nnual c overage f or

the y ear i n w hich t he e xpenses w ere i ncurred.

9) I a m n ot c urrently e nrolled i n a H ealth S avings A ccount ( an “ HSA”), o r i f I a m e nrolled i n a n H SA, I h ave f irst s atisfied t he h igh

deductible h ealth p lan’s a nnual d eductible f or t he y ear f or w hich t he e xpense w as i ncurred.

10) To t he e xtent m y c laim i s f or t he r eimbursement o f i nsurance p remiums, i f I ( or a n e ligible P lan D ependent) r eceive(s) a f ull o r

partial r efund o f a r eimbursed p remium f rom a ny m edical p rovider o r i nsurance c ompany, a fter b eing r eimbursed b y m y P lan, I

am o bligated t o r eturn t he r efunded a mount t o m y E meriti H ealth A ccount.

11) I f urther c ertify t hat I u nderstand t hat a ny p erson w ho, k nowingly a nd w ith i ntent t o d efraud o r d eceive, f iles a c laim

containing a ny m aterially f alse, i ncomplete o r m isleading i nformation m ay b e p rosecuted u nder s tate l aw a nd b e s ubject t o

civil f ines a nd c riminal p enalties. I h old S avitz, i ts a ffiliated c ompanies, o fficers, a nd e mployees, E meriti R etirement H ealth

Solutions, i ts o fficers a nd e mployees, T IAA-‐CREF T rust C ompany, i ts a ffiliated c ompanies, o fficers a nd e mployees, a nd m y

Plan h armless f or p ayment o f a ny i neligible e xpenses p resented i n s uch a m anner u nder t he t erms a nd c onditions o f t he

Emeriti R eimbursement B enefit.

Signature: _ _____________________________________ Date: _____________

Emeriti Qualified Medical Expense Claim Form Page 3

Related Articles

Related forms

Related Categories