Reimbursement Request Form

Request Form
Completion Guide
Step 1: Participant Information
Step 2: Reimbursement Information
• Plan Type: Enter the three- or four-letter code (located below the claim table) to identify the account from which you
are requesting reimbursement.
• Did You File Online?: If a claim was filed online using the Online Claim Submission Tool, mark “Y” for yes; if not, mark
“N” for no.
• Date(s) Expense(s) Incurred: Provide the date or range of dates the expenses were incurred.
• Merchant/Provider Name: Provide the name of the merchant or facility where the expense was incurred.
• Name of Person Receiving Product/Service: Provide your name or the name of the tax dependent for which the
service was provided or the product was purchased.
• Claim Amount: Provide the total amount requested for the specified expense.
• Total Reimbursement Requested: Total the amounts in the “Claim Amount” boxes.
Step 2a: Dependent Care Provider Signature and Certification
• Should the day care provider be unable to provide a receipt, a signature is required for your Dependent Care Account
(DCA) claim(s) to be paid.
Step 3: Participant Certification
• Sign and date the form after reading the Participant Certification.
Submit the completed form with the supporting documentation to:
UPMC Benefit Management Services
PO Box 2784
Fargo ND 58108-2784
Claims Fax: 1-844-361-4700
Email: [email protected]
Documentation Requirements
Documentation for medical expenses required by the IRS includes a third-party receipt containing the following
• Date service was received or purchase made
• Description of service or item purchased
• Dollar amount (after insurance, if applicable)
Documentation for dependent care expenses required by the IRS includes a third-party receipt containing the following
information (Please be advised: if a receipt is unavailable, a signature from the provider is sufficient):
• Incurred dates of service
• Dollar amount
• Name of day care provider
Unacceptable forms of documentation include the following:
• Provider statements that only indicate the amount paid, balance forward, or previous balance
• Credit card receipts that only reflect a payment
• Bills for prepaid dependent care/medical expenses where services have not yet occurred
When submitting a receipt for a copayment amount, be sure the copayment description is on the receipt. In some cases,
you will need to ask for a receipt at the point-of-service. If the “copayment” is not clearly identified, have the provider
write “copayment” on the receipt and sign it.
(Continued on next page)
This form is for the reimbursement of any out-of-pocket expenses. Documentation to substantiate purchases made
with your debit card must be submitted with a copy of a Receipt Reminder or a Receipt and Substantiation Form.
Step 1: Participant Information
*=Required Fields
*Employer Name (Do not abbreviate.)
*Member ID
*Participant Name (First, MI, Last)
Note: Reimbursements will be sent to the address on file with UPMC Benefit Management Services. If an address change
or update is needed, please contact your Human Resources Administrator to update.
Step 2: Reimbursement Information
If you are unable to provide a receipt for any claim(s) submitted for your Dependent Care Account, your day care provider
must complete Step 2a. If you would prefer to file only one claim for the plan year, please access the Recurring Dependent
Care Request Form in the Forms section of your FSA Participant Portal.
Step 2a: Dependent Care Provider Signature and Certification (for dependent care claims)
I certify the information provided above is accurate. I understand the purpose of my signature on this form is to eliminate
the necessity for the participant to provide receipts for reimbursement purposes.
*Dependent Care Provider Signature
Step 2b: Claim Information
*Plan Type¹
*Did You File
(Y or N)
*Merchant/Provider Name
*Name of Person
Receiving Product/
*Claim Amount
¹Plan Types FSA-Health Care FSA; DCA-Dependent Care FSA; LFSA-Limited Purpose FSA; PKG-Commuter Parking Account;
TRN-Commuter Transit Account; HRA-Health Reimbursement Account; HIA-Health Incentive Account
*Total Reimbursement
Requested =
Step 3: Participant Certification
I certify that the reimbursement requests I am submitting are eligible expenses as defined by the IRS and that I have
not been previously reimbursed for these expenses nor am I seeking reimbursement for these expenses from any other
source. I understand that UPMC Benefit Management Services, its agents or employees, will not be held liable if I submit
ineligible expenses for reimbursement. By submitting this request, I certify that the information provided is complete and
accurate. If there are any changes in the information provided, I understand it is my responsibility to notify UPMC Benefit
Management Services. I understand that I should retain a copy of all submitted documentation in the event of an IRS
*Participant Signature
Copyright 2014 UPMC Health Plan Inc. All rights reserved.
REIM REQ FM 14OP0424 (MCG) 12/31/14 PDF