Opec Funding Plan Claim Form – Fill Out and Use This PDF

	OPEC Funding Plan Claim Form
Employer Name				Send This Completed Form To:
				Ohio Public Entity Consortium
				P.O. Box 1135
Employee Name				Dublin, Ohio 43017
				Phone: 800-989-9095
				Fax: 614-873-2916
Employee Address (Number, Street, City, State, Zip)
Employee Social No.		Employee Date of Birth		Employee Phone No.

I request reimbursement from the funds available in my Funding Plan. The services are qualified under the

Plan and itemized below with my Explanation of Benefits from the Health Plan.

This section only required if information is not on EOB, Bill or Receipt

I certify that I have not requested reimbursement under this Plan or from any other source for the above expenses. I understand that I cannot claim expenses reimbursed under this Plan on my personal income tax return. I agree to reimburse the company for any liability that may incur for failure to withhold income tax or Social Security tax because of a non-qualifying reimbursement paid to me as a result of incorrect information provided by me.

I acknowledge that the expense(s) has (have) been incurred as substantiated by the attached documentation

and that they have not been, or will be, reimbursed by any other health Plan or other program.

Employee Signature

Date

Major Medical Claims: You must file with your primary insurance carrier and then submit your Explanation of Benefits (EOB).

Office Visit Co-Pays: You can submit your EOB or itemized Doctor's receipt showing your co-pay has been paid.