Claim Form Medcom – Fill Out and Use This PDF

FLEX CLAIM FORM

MAIL TO MEDCOMP.O. BOX 10269 JACKSONVILLE, FL 32247-0269

FAX TO  877.723.0149

EMAIL TO MedcomReceipts@emedcom.net

		EMPLOYEE NAME (Print)
		SOCIAL SECURITY NUMBER
	FLEXIBLE BENEFIT PLAN	 FORMER NAME, IF CHANGED
		 NEW ADDRESS, IF CHANGED

Street

City

State

Zip

YOUR CLAIM CAN NOT BE PROCESSED IF THE FOLLOWING SUBSTANTIATION IS NOT ATTACHED

Medical Claims: Insurance Explanation of Benefits (EOB); Medical Provider invoice containing diagnosis; Prescription for treatment, etc.

Dependent Day Care Claims: Invoices itemized by Payment Frequency* and with the name of the Day Care Provider, Tax- ID Number, dates of service and the name of person receiving the service.

Please reimburse me for:
Medical Expenses Totaling (FSA)	$
Dependent Day Care Expenses (DCAP) Totaling	$

DCAP CLAIMS WILL NOT BE CONSIDERED FOR PAYMENT UNLESS THE TWO QUESTIONS BELOW ARE ANSWERED

TOTAL SUBMITED

I hereby certify that the above requested reimbursement is for eligible services received by either myself or eligible tax dependents (if any). The above expenses are not payable to me or any eligible tax dependent(s) from any other source, nor will I seek reimbursement under any other plan or source covering health benefits. If the expense(s) is for Day Care, the dependent(s) is an eligible tax dependent. I may not claim the Dependent Care Tax Credit for any reimbursement I receive for this claim.

I further certify that I understand that I must immediately repay ineligible reimbursements. If I have a debit card, it will be deactivated until the full amount of any ineligible expenses is repaid; and, future claims may be off-set; or, at my employer's discretion, ineligible expenses may be payroll deducted from my paycheck. Additionally, because unsubstantiated expenses are considered ineligible expenses by IRS regulations, I understand that I am required to keep and submit receipts to substantiate expenses as requested by the claims administrator. And, I understand that funds I repay the Plan for ineligible expense may be used for reimbursement to me for eligible expenses incurred during the applicable Plan Year.

EMPLOYEE SIGNATURE

DATE

MEDCOM CUSTOMER SERVICE 800.523.7542 or 904.596.4500

If you have questions, refer to the Plan Document and Summary Plan Description for complete details regarding your benefits

CLAIM FORM FSA-DCA ed 0669