HTML Preview Voucher Form (Blank) page number 2.
* HOW TO COMPLETE YOUR REIMBURSEMENT VOUCHER *
FILLING OUT YOUR REIMBURSEMENT VOUCHER:
? Fill out your employer’s name, your name and your address. The address on the voucher is the address to which your
check will be sent. If there is a change of address, please check the “Change of Address” box.
? Be sure to fill in your Social Security number and your home and work telephone numbers.
? Sign and date your voucher. Your claim cannot be processed without your signature.
? Please provide a specific description of your expenditures under the “description” column.
? Fill out the total amount of your claim in each category — Medical, Dependent Care and Premium Expense.
SUBMITTING YOUR CLAIMS FOR REIMBURSEMENT:
? Please be sure that the claims that you are submitting for reimbursement are allowable expenses. There are some
specific expenses that are not allowed under various Flex plans. For example, cosmetic procedures, child care while
one spouse is at home, and spousal premiums for group-term life insurance are not reimbursable expenses. If you
have any questions regarding an allowable expense, contact PGP for clarification.
? You will need to attach copies of third party invoice(s) to substantiate your claim. These may include receipts,
insurance Explanation of Benefits (EOB) or other documentation. Canceled checks cannot be accepted as proof of
a reimbursable expense. Each invoice must contain the following information:
? Date of Service. Reimbursement is made based on date of service, not on date of payment.
? Nature of Service. Receipts must specify the nature of service so that we may determine its eligibility under
the Flex plan.
? Individual Receiving Service. Only plan participants and their dependents may be eligible for Flex benefits.
? Amount of Service. Please provide documentation indicating the cost of services for which you are
responsible.
? ?? UNREIMBURSED MEDICAL EXPENSES:
? Certain UNREIMBURSED MEDICAL EXPENSES may require a prescription from a licensed physician
indicating the medical necessity, and condition, for which the items are required. A new prescription is
required for each condition, and for continuing conditions at the beginning of each plan year. If you have
already submitted the necessary documentation to PGP, be sure to indicate that by checking the box provided
on the voucher under Unreimbursed Medical Expenses. Please contact PGP if you have any questions
regarding the necessary documentation for expenses.
? Expenses covered by your insurance can only be submitted to PGP after they have been submitted to your
insurance carrier. When you receive your Explanation of Benefits, submit the unpaid balance to PGP. We
cannot reimburse you before we know how much of your claim will be covered by your insurance carrier.
? Expenses not covered by your insurance should be submitted along with a statement from either you or your
insurance carrier indicating that the expenses will not be reimbursed.
? DEPENDENT CARE
? For DEPENDENT CARE claims please list your provider’s name and either Social Security or Tax ID
number.
? You can submit vouchers at any time, but you will only be reimbursed up to the amount that is in your
Dependent Care Account at the time your voucher is received. The balance of the claim will be paid
automatically as money is deposited in your account.
? PREMIUM EXPENSE
? For PREMIUM EXPENSE claims, provide a third party invoice showing the type of insurance, the time
period the insurance covers, the individual receiving coverage, and the amount of the premium. You will
be reimbursed only for the coverage that falls within your plan year.
If you have any questions regarding your Flex Account, please contact
The Preferred Group at (518) 641-0321 or (800) 573-7474
from 8 AM to 6 PM Monday through Friday.