Medical Expense Claim
For Donovan & Bank Foundation QSEHRA
Employee
Please Select
Paul
Stu
Dan
Drew
What are you claiming?
Insurance Premiums (Tricare, Vision, Dental)
Medical/Dental/Vision Treatment Expenses (paid to facility)
OTC Expenses
Premium MONTHLY Payment
*
Months Claimed
*
# of months you are claiming the above premium for
Premium Total:
Carrier/Plan Name
Type of Insurance
Please Select
Tricare Prime/Select
Vision
Dental
Medical Expenses (list each transaction individually)
*
OTC Purchases (list amount as listed on receipt per item, we'll calculate sales tax)
*
Enter the % of sales tax (NC is 7)
*
Enter the whole number. i.e. 7%, not .07
Sales Tax
Total Amount for OTC Purchases
Attach Receipts or EOB
Browse Files
Drag and drop files here
Choose a file
Upload an itemized receipt or EOB. Credit card statements alone are not sufficient. For OTC, the receipt must show product name (highlighted); keep packaging photos if the receipt is unclear.
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of
Notes to Administrator
Premium Total:
Total Amount for OTC Purchases
Treatments Total
Total Reimbursement Claimed:
Please consent to the following:
*
I (and any family member for whom I’m claiming expenses) had Minimum Essential Coverage for each month of the expense(s). I will provide proof upon request.
These expense(s) are not reimbursed or reimbursable by any other plan or account (including spouse’s cafeteria plan, FSA, HSA, or TRICARE).
Any family member included is my spouse or tax dependent under IRC §152.
I certify the information and documents are true and agree to repay any amounts paid in error.
I understand claims for a calendar year must be submitted by January 31 of the following year and unused amounts do not carry over.
I consent to follow-up via my work email for claim questions.
Employee's Signature
Name
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Submit
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