Listed below are guidelines for processing claims for your Medical Bank and/or Dependent Care flexible spending accounts. 

> Claims must be submitted using the reimbursement claim form. Complete all sections of the claim form. Incomplete forms will be returned. Staple documentation to the claim form so it is not lost.  

> Med bank claims must include an explanation of benefits (EOB) or an itemized statement of the expense that includes: the date the service was provided, the service provider, the patient name, type of service, what insurance has paid, the cost of the service and the patient responsibility. Canceled checks, credit card statements, estimations, pre-determinations or receipts that do not include the above information are not sufficient alone to receive a reimbursement. No exceptions will be made.

Cash register receipts for over-the-counter medication will be accepted. Receipt must show medications purchased and date of purchase. Please circle medications requesting reimbursement. Tax will not be reimbursed.

> Dependent care claims must include the provider's Tax ID number and address on the claim form. Receipts (originals or copies) indicating that you have paid for the services, including the dates the services were provided, must be included to receive reimbursement. No exceptions will be made.

> Completed forms must have an original signature of the employee. Faxed forms will not be processed.

> Per Section 125 of the IRS codes, an employee cannot make a change to the annual election amount for that calendar year unless they experience a Family Status Change. In addition, per Section 125, employees must use their money or lose it. Unclaimed funds are forfeited if they are not submitted for reimbursement by January 31st for Dependent Care, or March 15th for Med Bank of each subsequent year.

Please contact the OFM-Benefits Division if you have questions or require additional information.