Fillable Reimbursement Request Form Mdea, Dcea & Hra (Rev. 12/2015) (Page 3 of 3) in pdf

For toll-free support, call 121 Benefits at 1-800-300-1672 or from the Twin Cities Metro area, call 612-877-4321. When calling, please

identify yourself and your employer, and have available your State Employee ID Number.

Minnesota Management & Budget

NOTICE OF COLLECTION OF PRIVATE DATA

Minnesota Management & Budget administers the State Employee Group Insurance Program (SEGIP). We are requesting

data from you through a vendor, 121 Benefits, which has been authorized to administer the State of Minnesota Pre-tax

Benefits Plan. This notice explains why we may request information (data) about you, your dependents and beneficiaries, how

we will use it, who will see it, and your obligation to provide that information.

What information will we use?

We will use the information you provide us at this time, as well as information you have previously provided us about

yourself, your dependent(s), and/or your beneficiary. If you provide any information about yourself or your dependent or

beneficiary that is not necessary, we will not use it for any purpose.

SEMA4, the information system used to administer employee benefits, contains required information fields that may not be

necessary for us to process your request. We do not need the gender or marital status for your beneficiary designation, so you

may enter “unknown” in these fields. We only need your dependent’s date of death to process a death benefit claim or to

discontinue the dependent’s coverage due to his or her death. Student status and disability status are needed only to

determine eligibility for insurance continuation for your dependent. We only need your dependent’s social security number to

offer insurance continuation or process a death benefit.

Why we ask you for this information?

We ask for this information to process your request to add or change coverage for yourself, your dependent or a beneficiary.

The requested information helps us to determine eligibility, to identify you and your dependents and beneficiaries, and to

contact you or your dependents and beneficiaries. We use the information so that we can successfully administer SEGIP,

including analyzing unidentifiable aggregate data to develop new programs and ensure current programs are effectively and

efficiently meeting member needs. We may ask for information about you that we have already collected, including all or part

of your social security number, in order to ensure we are matching you to the correct change request or other insurance

benefit transaction.

Do you have to answer the questions we ask?

You are not legally required to provide any of the information requested.

What will happen if you do not answer the questions we ask?

If you do not answer these questions, the insurance benefit transaction you requested for you or your dependent or other

insurance benefit transaction may be delayed or denied.

Who else may see this information about you and your dependents and beneficiaries?

We may give information about you and your dependents and beneficiaries to the insurance carrier you have chosen, SEGIP’s

representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement agency or

other agency with the legal authority to the information, and anyone authorized by a court order. In addition, the parents of a

minor may see information on the minor unless there is a law, court order, or other legally binding instrument that blocks the

parent from that information. We can use or relates this information only as stated in this notice unless you give your written

consent to authorize release of the information to another person/entity, or if Congress or the Minnesota Legislature passes a

law allowing or requiring us to release the information or to use it for another purpose.

Reimbursement Request Form Mdea, Dcea & Hra (Rev. 12/2015) Page 3