In order to file a Medical Reimbursement (Medflex) or Dependent Care (Careflex) or Premium Reimbursement Claim, participants must attach a written statement from an independent third party (such as an Itemized Statement, Explanation of Benefits (EOB), or a Pharmacy printout of prescriptions filled) to a Reimbursement Request Form. Documentation must include the date of service, the provider of services, procedure performed and the amount you are being charged. Charge receipts, cancelled checks, balance forwards and paid on account receipts are not acceptable documentation.
Make sure you have signed, dated and put your employer’s/company name in the appropriate area. In signing the form, the participant is providing a written statement that the expense has not been reimbursed or reimbursable under any other source.
Click on the link to complete and print or fill in a Reimbursement Request Form/Claim Form. Sign your form, attach documentation that supports your claim and send to Glynn Griffing & Associates. Frequency of Claims processing is determined by your employer.