Fillable Flexible Spending Account Claim Form (Page 2 of 2) in pdf

Reimbursement Information

Health Care Expenses

Dependent Care Expenses

Any dependent care expenses you claim must be for the care of a dependent

You may be reimbursed for certain health care expenses which

under age 13, disabled dependent or a disabled spouse – so that you (and

would otherwise be a deductible item of your Federal income tax

your spouse, if you are married) can work. In order to be reimbursed, the

return.

expenses must meet the following requirements:

You may receive up to the amount you have agreed to contribute

for the current year by supplying the necessary documentation

The expenses must be for a qualifying person; a dependent under

verifying the claim. This documentation should be the

the age 13 for whom you claim a dependency exemption for tax

Explanation of Benefits from an insurance company describing the

purposes, or a spouse or dependent who is physically or mentally

outstanding balance being claimed. If you do not have insurance,

not able to care for himself or herself.

and only then, a detailed bill or receipt can be used.

The expenses must be for the well-being and protection of a

Expenses covered by another available medical plan, should be

qualifying person so that you (and your spouse, if married) can

filed as a Medical Plan claim prior to being submitted as a

work. Expenses for services necessary to run your home by a

Spending Account claim.

housekeeper or maid are covered if they are partly for the well-

being and protection of a qualifying person. Expenses for food,

The expense being claimed may not be reimbursed from any

clothing, education or entertainment for a qualifying person are

other sources or deducted on your personal income tax.

not covered.

If care is provided outside your home for a disabled spouse

Examples of eligible expenses are: medical plan deductibles and

or dependent, he/she must spend at least eight hours each day in

copayments, amounts over usual and customary allowance, vision

care expenses, dental care expenses and orthodontic, routine

your home.

physicals, hearing exams and hearing aids, vision exams and

glasses, eligible over the counter expenses with a prescription,

If care is provided for your child under age 13 in a day care facility

travel expenses primarily for and essential to health care and

that provides care for seven or more individuals and receives a

health care associated with adoption. All such expenses must

fee – that facility must comply with all state and local regulations.

have been incurred during the plan year claimed.

The care provider cannot be your dependent for tax purposes, or

All other health care expenses which have not been processed

your child, if your child is under 19. The care provider can be a

under the provisions of the Medical Plan should be supported by

relative who is not your dependent, even if he/she lives in your

bills which state:

home.

If you are married, your spouse must work or be a full-time

provider name and address

student. Also, the total amount of reimbursement for the plan

person receiving service

year cannot exceed the income of the lower paid spouse.

date of service

type of service or supply

The expenses reimbursed under this plan cannot be claimed as a

amount of charge for service or supply

tax credit on your return. Any amounts not reimbursed can

be applied toward the tax credit.

If your claim includes travel expenses associated with health care,

record your computation of mileage for your records. Travel

Documentation from the dependent care provider must

mileage to obtain health care must meet IRS regulations. You may

accompany the claim form. Copies of the paid bill or a receipt

deduct out-of-pocket expenses for your car as specified by the IRS

from the dependent care provider are examples of the required

or use the IRS annual standard mileage rate. Add parking and tolls

documentation.

to the amount you claim under either method.

Refer to IRS Publication 503 for detailed information on eligible

Please provide proof of the appointment you are traveling to,

dependent care expenses. Services must, however, be incurred in

such as a receipt from the doctor, hospital or the EOB.

the year claimed.

Refer to IRS Publication 502 for detailed information on eligible

health care expenses. Services must, however be incurred in the

year claimed.

You have three months after the end of the calendar year to submit any claims. If you terminate your employment during the calendar year, you will

have three months after the termination of your health benefits to submit any claims. When submitting claims for either the Health Care Spending

Account or the Dependent Care Spending Account, third party documentation verifying the expenses have incurred must accompany the claim form.

Fax page one of claim form along with supporting documents to: 906-487-3220 or mail to:

Benefits Office

Michigan Technological University

1400 Townsend Drive

Houghton, MI 49931

04/28/2015

Flexible Spending Account Claim Form Page 2

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