In order to file a Medical (Medflex) or Dependent Care (Careflex) reimbursement, 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.
Per IRS regulations, documentation must include:
- Date(s) of service
- Provider and/or merchant name
- Name of person who received the service
- Detailed statement of services rendered or procedure (CPT/ADA) codes
- Amount charged for each procedure
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.