Reimbursement Form_Medical Expenses Template

This reimbursement form_medical expenses template has 2 pages and is a MS Word file type listed under our human resources documents.

Sample of our reimbursement form_medical expenses template:

HEALTH EXPENSES REIMBURSEMENT FORM IDENTIFICATION Employee Name: Phone: Social Security Number: Date: Employee Number: Email: Position/Title: Dept: MEDICAL EXPENSES Date of Service Physician or other Provider Amount TOTAL MEDICAL EXPENSES TO BE REIMBURSED I have HEALTH insurance: Yes No DENTAL insurance: Yes No VISION Insurance: Yes No DEPENDENT/CHILD CARE EXPENSES Name of Dependent Care Provider: Provider's Taxpayer ID# Address of Provider: Name of Dependent(s): Services From:To: Amount: From:To: Amount: From:To: Amount: TOTAL DEPENDENT EXPENSES TO BE REIMBURSED Signature of Care Provider Date: I certify that the statement and information on this reimbursement form are accurate and true. I also certify that I am claiming reimbursement for only eligible expenses incurred during the plan year and only for eligible plan participants. I certify that these expenses have not been or will not be reimbursed under this or any other benefit plan. I further certify I will not claim these, or any other expenses reimbursed through this plan, as an income tax deduction and I assume all liability for taxes and penalties out of any disallowed deduction/credit. Employee Signature: Date: *If you DO NOT have a receipt your claim will not be reimbursed unless your daycare provider has signed this form. FOR ADMINISTRATIVE USE ONLY Reviewed By: Date: Plan Year: Approved: $ Denied: $ Reason for Denial: Action: INSTRUCTIONS FOR MEDICAL AND DEPENDENT CARE REIMBURSEMENT ACCOUNTS Only employees participating in the plan can submit a reimbursement form; employees may be reimbursed from the plan at any time during the plan year. Reimbursements may only be made for eligible expenses incurred during the plan year. Complete the information on the reimbursement form for each amount claimed