Reimbursement Claim Form

When filing a claim please read the second page of the claim form for the directions and information needed to process the claim. Please note you must have current medical insurance to file a claim for reimbursement.

The deadline for submitting a claim for 2024 plan year is June 15th 2025.

The deadline has past for filing a claim for any other previous plan years.

You can mail in the claim form and supporting documents to the address provided. If you would like to fax the claim in it must be legible and have a completed claim form with it. If you would like a digital link to upload to us you will need contact our office to request this service as it requires a couple of extra steps.