Rocky Mountain Claim Form PDF Details

Navigating through the complexities of healthcare and dependent care expenses can often feel like an uphill battle. With the introduction of forms like the Rocky Mountain Claim form, strides have been made towards simplifying the reimbursement process for these critical expenses. This form serves as a key tool for individuals covered under a company's Flexible Spending Account (FSA), allowing them to claim reimbursement for qualifying healthcare and dependent care expenses incurred within a specified Plan Year. It underscores the importance of submitting accurate and truthful information, as the person filling out the form bears sole responsibility for the data provided. Highlighting a stringent verification process, it requires the inclusion of third-party receipts or statements as proof of service to ensure that only legitimate claims are reimbursed. Rocky Mountain Reserve, acting as the claims paying agent, facilitates the reimbursement process directly from the general assets of the employer, emphasizing that there is no separate fund or account designated for the plan benefits. This form encapsulates a crucial aspect of managing healthcare and dependent care expenditures, thereby providing a structured pathway for individuals to navigate their claims within the framework of an FSA, thereby underscoring its importance in the broader context of personal financial planning and healthcare management.

QuestionAnswer
Form NameRocky Mountain Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrockymountainreserve com, rocky mountain reserve fsa login, rocky mountain spotted fever forms for disability to be off work, forms

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All expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Company's Flexible Spending Account with respect to such expenses.
All expenses were incurred (service provided) in the Plan Year indicated above. Both medical expenses and/or dependent care expenses are “qualifying” expenses.
Medical expenses have not been reimbursed or are not reimbursable under any other health plan coverage.
The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information provided by the undersigned, and
that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan which relate to such expense.
Rocky Mountain Reserve is a mere claims paying agent of the employer. All reimbursements are paid out of the general assets of the employer. There is no separate fund or account for the plan. There is no separate fund or account that secures Cafeteria Plan benefits.

CLAI M FORM

PO Box 631458 Littleton, CO 80163

P:(888) 722-1223 F: (866) 557-0109 claims@rmrbenefits.com www.RockyMountainReserve.com

Name:

Employer:

 

Email Address

 

 

 

SSN

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

Dayt ime Phone Number

 

PLAN YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Expenses

Accounts: FSA = Flexible Spending Account, HRA = Health Reimbursement Arrangement, OIP = Outside Insurance Premium Account, PKG = Qualified Parking Account, TRN = Qualified Transportation Account

Date of Service

Account

Type of Service

Patient

Amount

Dependent Care Expenses

 

 

 

TOTAL CLAIMS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Service

 

Dependent Name

 

 

Amount

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daycare Provider Information:

TOTAL CLAIMS:

Name: _____________________________________________ Provider Signature:_________________________________________

(Provider name and signature is only required in the absence of a receipt from the daycare provider)

The undersigned participant in the Plan certifies the following:













A copy of a third party receipt, bill or statement showing an amount and proof of service (not just payment) must be included in order to process this claim.

Employee Signature

Date

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