Instructions: Failure to complete all sections of the form may delay the processing of your claim.  

Complete Part I: For all types of claims.

Complete Part II: for any medical, dental, vision, over the counter, dependent care, etc. type of expenses.

You must document each expense by either attaching itemized receipts or have the provider complete the provider certification section (daycare only).  Attach copies (please do not send originals) of the receipts or explanation of benefits (EOBs) for each expense showing:

1.  Who the service is for.
2.  The provider or store name.
3.  The date the service was received (not the paid date).
4.  The amount of the service.
5.  The nature of the expense.

If you are submitting more than one expense, please attach the receipts in the order the claims are listed on the form.

Sign and date the form and hit submit, you will receive an email confirmation  of expense submission once submitted.