Request For Reimbursement Form
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1402 Graham Avenue • PO Box 1128 • Eau Claire, WI 54702-1128 PHONE: (800)236-7789 • (715)832-5535 • FAX: (715)838-8507
Request for Reimbursement Form
Full Name (Last, First, MI)
Phone Number
Address (Street, City, State, Zip)
Group Name
ID Number
Group Number
Directions for using this Claim Form
For each of the accounts in which you are submitting claims, please complete the appropriate section then attach the documentation for the
expenses listed. Documentation must contain the patient name, date(s) of service, service received, expense incurred and the name of the provider
of service. If the expense is covered under any Medical or Dental plan, attach a copy of the Explanation of Benefits received from the carrier
showing their determination of the claim.
Medical Expense Claims
Date of Service
Patient Name
Name of Provider
Description of Service
Claim Amount
MM/DD/YY
$
$
$
$
$
Total: $____________
Dependent Care Claims
Date of Service
Dependent Name
Dependent Care Provider
Provider Tax ID# or SSN
Claim Amount
From:_____To:______
Name
$
$
$
$
$
Total: $____________
EMPLOYEE’S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were
not reimbursed by any other plan, and, to the best of my knowledge and belief are eligible for reimbursement under my reimbursement plans. I (or
we) will not use the expense reimbursed through this account as deductions or credits when filing my (our) individual income tax return. Any
person who knowingly & with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider, files a
statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Signature___________________________________________
Date_______________________
REIMBURSEMENT REQUEST MAY BE FAXED TO: (715)830-5270
OR MAILED TO: BENEFIT PLAN ADMINISTRATORS
PO BOX 1128
EAU CLAIRE, WI 54702-1128
You may also visit our website at to review your account information.
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Parent category: Business