Please attach a receipt or itemized bill listing (A),(B),(C), (D) and (E) or have provider certify below.
Cancelled checks or bills showing a payment or previous balance only are not acceptable. 

PROVIDER'S CERTIFICATION/VERIFICATION

I certify that the above-described Dependent Care expenses were incurred by the employee named above.

Please attach a third-party receipt,itemized bill or Explanation of Benefits (EB) Listing (A),(B),(C),(D) and (E) or have provider certify below. Cancelled checks,credit card receipts or bills showing a previous balance or balance due only are not acceptable

I certify that the above-described unreimbursed medical expenses were incurred by the employee named above.

Please provide your electronic signature before we process your request. When you check the box, you agree the information you provide is accurate and complete to the best of your knowledge. Any attempts to commit fraud against the Myles Financial Service or it affiliate, may be subject to administrative penalties and/or criminal prosecution. Checking the box creates an electronic signature. An electronic signature is similar to your handwritten signature. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge.

Business/Provider Signatures                            Address  Date

Please complete dependent information:

Dependent Name Date of Birth SS# Relationship

FLEXIBLE SPENDING MEDICAL ACCOUNT

1. Complete this form, sign, date and submit. Failure to complete will result in a delay of processing of this claim.

2. Attached itemized bills, receipts or explanation of benefits which show:

  a. Name of person receiving service;

  b. Nature of service or supplies furnished and charges for each item;

  c. Dates of such services;

  d. Names of providers, addresses and tax identification number.

3. If no receipt, the provider/business may sign this form in lieu of receipt.

4. If you carry group insurance, FIRST submit expenses to the insurance carrier. Attach the explanation of benefits to document any reimbursement or credit to your deductible.

Qualifying Expenses

To qualify for reimbursement, expenses must be incurred during the Plan Year for which you are requesting reimbursement.

6 Unreimbursed Medical Accounts - can ONLY be used for out of pocket medical expenses for you and your family which are not covered by any other health plan. Items covered include but are not limited to:

  a. Deductibles/co-insurance

  b. Medical,dental and vision services;

  c. Hearing exams or aids.

  d. Prescription Drugs / Co pays.

  e. Over the Counter Drugs & Supplies related to health care, not for convenience or cosmetic use.

Dependent/Child Care Account – reimbursement for care of your child or other tax dependent while you are at work. For services at a dependent care center, the center must comply with all state and local laws.

Specification for this account are:

a. Your child must be age 12 or under;

b. Your child or other dependent over the age of 13 must be incapable of self support and spend 8 hours or more a day in your home;

c. The individual caring for your child age 12 or under or other dependent must not be a tax dependent;

d. Reimbursement cannot exceed $5,000 annually($2,500 if married filing separate returns) or the earned income of you and your spouse, whichever is less;