Wyoming Medical Reimbursement Form PDF Details

In Wyoming, employees have the opportunity to utilize the Medical Reimbursement and Dependent Care Account Claim Form under the State of Wyoming Flexible Spending Plan. This form serves a dual purpose: it allows individuals to request reimbursement for eligible medical and dental expenses not covered by insurance for themselves, their spouses, and dependents, and it also provides a means for employees to claim reimbursement for dependent care expenses that enable them to work. To successfully submit a claim, employees must provide detailed information including their agency name, social security number, contact details, and specifics about the expenses they are claiming. The form requires a thorough documentation of medical or dependent care services provided, including the date of service, provider details, and the amount requested for reimbursement. Attachments of itemized invoices and an Explanation of Benefits (EOB) from any applicable insurance are necessary to process the claim. Moreover, the form outlines that only expenses not eligible for reimbursement from any other source may be claimed and that these reimbursed expenses cannot be declared as deductions or credits on personal tax returns. Claims can be submitted semi-monthly, and the process details reimbursement checks issued by the Employees’ Group Insurance Office, which also offers further assistance and information. Notably, it emphasizes compliance with Internal Revenue Code guidelines for expense eligibility and highlights potential tax implications for expenses deemed ineligible by the IRS or if an overpayment occurs. The form concludes with a requirement for the employee's original signature to validate the request, underscoring the importance of accuracy and honesty in the submission.

QuestionAnswer
Form NameWyoming Medical Reimbursement Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical reimbursement form, how to fill medical reimbursement form, wyoming medical reimbursement account, state of wyoming flexible spending claim form

Form Preview Example

MEDICAL REIMBURSEMENT AND

DEPENDENT CARE ACCOUNT CLAIM FORM

STATE OF WYOMING FLEXIBLE SPENDING PLAN

Agency Name

Agency #

Social Security Number

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

Home Address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUEST FOR REIMBURSEMENT FROM THE MEDICAL ACCOUNT

This section must be completed in its entirety

 

Date of

 

 

Patient

Requested

Service Provider Name

Service

 

Name

 

Relationship Age

Amount

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

Total Medical Reimbursement Requested

 

$

REQUEST FOR REIMBURSEMENT FROM THE DEPENDENT DAY CARE ACCOUNT

This section must be completed in its entirety

 

Date of

 

Dependent

Requested

Name & ID# of Provider

Care

Name

Relationship/Age

Amount

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

Total Dependent Care Reimbursement Requested

 

$

Dependent Care Provider Signature (Receipt may be attached in lieu of signature)

Please sign on back page

FOR OFFICE USE ONLY

Date Received

Date Paid

You must attach an explanation of benefits (EOB) for any item covered by any insurance you have.

These services are not allowable under my and/or my spouse’s and/or dependent’s insurance policy for the following reason(s):

ITEMIZED INVOICES AND AN EXPLANATION OF BENEFITS FROM INSURANCE COMPANY MUST BE ATTACHED.

GENERAL

Requests for reimbursement may be submitted at any time. Semi-monthly reimbursement will be made directly to you. Reimbursement checks will be issued two times during the month (see the current reimbursement claims processing schedule).

If you apply for reimbursement of expenses that the IRS later determines to be ineligible, those reimbursements may be taxed as ordinary income and IRS penalties may apply. Similar treatment may apply to overpayment of reimbursed expenses that have already been reimbursed from some other source.

MEDICAL REIMBURSEMENT

Eligible expenses are qualified medical/dental expenses of the employee, spouse, and dependent(s) that are not eligible for reimbursement from any other source. Expenses that are eligible for reimbursement under a health insurance plan should not, for example, be included on this form. A list of typical IRS approved medical/dental expenses is documented in your Flexible Benefit Plan Summary. General information on the Employee Reimbursement Accounts as well as claims status may be obtained by contacting the Employees’ Group Insurance Office at 777-6835 or 1-800-891-9241.

I request reimbursement from the Employee Reimbursement Account(s) for the expenses itemized above. I hereby certify that I have read and understand the guidelines on this form and that these expenses must qualify for reimbursement under the Internal Revenue Code as outlined on the form.

I further certify that these expenses are not eligible for reimbursement from any other source. I also understand that reimbursement expenses cannot be claimed as credits or deductions on my personal tax return.

DEPENDENT DAY CARE REIMBURSEMENT

Expenses to provide care for your eligible dependents may qualify for reimbursement. Eligible dependents include children under age 13, a disabled child, a disabled spouse, or a dependent disabled parent.

To be eligible, you must be working while your dependents receive care. Also, if you are married, your spouse must be:

−A wage earner, or

−A full-time student for at least 5 months during the year, or

−Disabled and unable to provide for his or her own care.

Expenses eligible for reimbursement are those incurred to enable you to be gainfully employed, and include covered charges by:

−Licensed nursery schools and day care centers

−Individual – other than your dependents – who provide care for your children in or outside your home, or for your disabled spouse or dependent parent in your home.

−Housekeepers, maids or cooks in your home, to include their food and lodging in your home, as long as their services are performed for the benefit of your eligible dependent(s).

Under IRS Regulations, qualified individuals can receive a tax credit for dependent care costs. This credit is claimed on your personal tax return. You CANNOT claim the tax credit for any dependent care costs reimbursed from the Employee Reimbursement Account.

Employee’s *original Signature

Date

*This form requires an original signature and will not be processed if the signature is a copy.

Submit Claims to:

Department of Administration & Information

Human Resources / Employee Benefits

Attn: Cafeteria Plan Section

2001 Capitol Avenue

Emerson Building, Room 106

Cheyenne, WY 82002

(307) 777-6835

Revised 1/26/07 EGI-105

How to Edit Wyoming Medical Reimbursement Form Online for Free

Working with PDF forms online is actually simple with our PDF tool. Anyone can fill in wyoming form spending here with no trouble. The editor is consistently improved by our team, acquiring cool functions and becoming better. Getting underway is simple! All you should do is follow the next simple steps down below:

Step 1: Click on the "Get Form" button above. It will open up our pdf editor so that you can start completing your form.

Step 2: The editor helps you work with PDF forms in various ways. Change it by writing your own text, adjust what's already in the PDF, and place in a signature - all manageable within minutes!

This PDF requires specific information to be typed in, therefore you should definitely take some time to provide precisely what is required:

1. The wyoming form spending needs particular details to be inserted. Ensure that the following blanks are filled out:

Completing section 1 in medical reimbursement form

2. Just after this selection of blanks is done, go to type in the applicable details in all these: Service Provider Name, Total Medical Reimbursement, REQUEST FOR REIMBURSEMENT FROM THE, This section must be completed in, Name ID of Provider, Date of, Care, Dependent, Name, RelationshipAge, Requested, Amount, Total Dependent Care Reimbursement, Dependent Care Provider Signature, and FOR OFFICE USE ONLY.

Filling in segment 2 of medical reimbursement form

3. This third segment should also be rather easy, cid You must attach an explanation, following reasons, ITEMIZED INVOICES AND AN, DEPENDENT DAY CARE REIMBURSEMENT, Disabled and unable to provide, Expenses eligible for, and Licensed nursery schools and day - all these empty fields will need to be filled in here.

Expenses eligible for, ITEMIZED INVOICES AND AN, and Disabled and unable to provide in medical reimbursement form

As for Expenses eligible for and ITEMIZED INVOICES AND AN, be certain you double-check them in this current part. These two are certainly the most important ones in the page.

4. Filling in Employees original Signature, Date, This form requires an original, Submit Claims to, Department of Administration, Human Resources Employee Benefits, Attn Cafeteria Plan Section, Capitol Avenue, Emerson Building Room, Cheyenne WY, and Revised EGI is key in this next section - make sure to spend some time and take a close look at each and every empty field!

Step # 4 in filling in medical reimbursement form

Step 3: Before moving on, it's a good idea to ensure that all blank fields have been filled in the proper way. When you confirm that it's fine, click on “Done." Go for a 7-day free trial option at FormsPal and get instant access to wyoming form spending - with all changes saved and accessible from your personal account page. FormsPal ensures your data privacy via a protected system that in no way records or distributes any sort of personal information typed in. Rest assured knowing your docs are kept safe any time you use our service!

Wyoming Medical Reimbursement Form isn’t the one you’re looking for?

Related Documents