2016 Inpatient/Outpatient Co-Pay Claim Form Living Resources Corporation

r Reimbursement Claim / REMEMBER TO:
/ ü Print all information
ü Save a copy of all receipts and claim form before submitting to Human Resources for processing
ü Make copies of this form, as needed
Employee Information

Last Name First Name Mi I Social Security #

Mailing Address City/State Zip Check if New Address

Claim Information

Please attach copy of Explanation of Benefits from the health insurance carrier reflecting the Date of Service of the inpatient hospital and/or outpatient surgery co-pay.

Date of Service / Person receiving Services / Type of Service / Claim Amount
rSelf r Child rSpouse / r CDPHP - Inpatient Hospital Co-Pay / $800.00
rSelf r Child rSpouse / r CDPHP - Outpatient Surgery Co-Pay / $120.00
rSelf r Child rSpouse / r MVP – iNPATIENT hOSPITAL cO-pAY / $600.00
rSelf r Child rSpouse / r mvp – oUTpATIENT sURGERY cO-paY / $120.00
ü All information must be completed in order to process your claim. / TOTAL / $

I have attached originals or LEGIBLE copies of supporting documents, such as bills and statements (EOB’s from the insurance company as to the uninsured part of the expense). No expenses submitted for reimbursement are eligible for payment from any health and/or dental plan under which I, my spouse, and/or dependents are covered. I understand that expenses for my spouse and tax dependent child(ren) are only eligible for reimbursement if I completed an enrollment form for coverage including these individuals. I understand that I cannot deduct such costs as expenses on my individual Federal and State Income Tax Returns.

I certify that the above information is correct and complete and I have not submitted a previous claim for these expenses.

Mail completed claim form and documentation to:

Joe LaMalfa, Living Resources Corp., 300 Washington Avenue Extension, Albany, NY 12203.

Signature: / Date:
þEMPLOYER SECTION: The above employee and/or dependent is enrolled in the CDPHP OR MVP health insurance plan and the claim submission has been approved
______
Authorized Employer Signature Date

Inpatient Hospital and Outpatient Surgery Co-Pay Reimbursement Instructions

Since you are enrolled in CDPHP or MVP Health Insurance, you are now a participant in the Living Resources Inpatient Hospital and Outpatient Surgery Co-Pay benefit plan. This letter contains important information about submitting receipts for reimbursements.

The plan year runs from 1/1—12/31 and you have 90 days after the plan year ends to submit claims for expenses incurred during the plan year.

All expenses must be submitted with either a legible copy or original of the receipt or bill, or explanation of benefits (EOB) from CDPHP or MVP health insurance plan, or a claims history report from CDPHP/MVP. The date on which the expense was incurred and for whom must also be shown on the receipt or statement along with the provider’s name and address. Canceled checks or credit card receipts are not acceptable documentation for services rendered.

Important

All claim forms must be signed, dated and include your Social Security Number. Mail your completed claim form and documentation to the address listed on the claim form, which is:

Joe LaMalfa

Living Resources Corporation

300 Washington Avenue Extension

Albany, NY 12203

All claims submitted to us for consideration must follow the above rules and guidelines established by the IRS. Also, please remember that no expenses reimbursed under this plan may have been reimbursed by any other plan and cannot be deducted on your individual federal or state income tax returns.