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Uninsured Health Plan Claim Verification

January 1, 2010

For a printable version of this form that can be submitted by fax or mail, click here.

Payments made by an employer to cover uninsured health care expenses must be verified by an independent third party in order to avoid wage and income taxes.  The sole purpose of this service is to allow an independent benefit plan adviser to validate the tax-free status of cash benefits provided under an employer-provided health plan for the purpose of the employer's wage tax reporting. 

Please use this form to request a reimbursement under your company's health plan or to void paying wages taxes on cash payments that you may have already received from the employer's health plan.  This form is not for claims covered by an insurance plan.  All information collected is strictly private and used by the plan adviser only for the purpose of validating claims for wage and income tax purposes.  Only your name and the total amount of qualifying claims are reported to the employer or payroll company that may process the payments.  The employer does not have access to your private medical information or any information that you may provide in this form.  Check the MedSave.com User Agreement and Privacy Policy for more details.

Name    

E-Mail Address

Employer

Claims Detail

The "Description" is for your identification purposes only.  It is acceptable to leave it blank for privacy or write "Private claim #1", for example.  "Date" may be approximate, but must be within the plan's allowable claim reporting period.  "Amount Paid" should be only the amount you can document with paid receipts.  

Example:  "Kymberly / dental care    12/10/02       $176.50" 

Person and Description               Date                         Amount          

(If you have more than four claims to report, just submit a second copy of this form).

  1. Were any of these claims already paid by the employer through a debit card or other method?   (If yes, please indicate above which claims, if any, are still unpaid).                                                                      
  2. All of the claims listed above were incurred by a person covered by the health plan   
  3. Are any of the expenses covered by any other insurance or health plan?   
  4. I have written receipts showing both the charges and evidence of payment for all of the claims listed above.   
  5. I have determined that the expenses listed above are "qualified medical expenses" by either: 1) consulting IRS Publication 502 and making the determination on my own, 2) consulting with the Plan Adviser whose services were made available to me by my employer at no expense to me, or, 3) consulting with my own tax adviser.   
  6. I understand that if the amount of reimbursed claims are later determined by the employer or the IRS to be "not qualified" under the plan then I will be responsible for taxes and possible tax penalties on the amount received?  
  7. If a claim for prescription drugs is submitted, I verify that they were purchased legally within the U.S. and were not imported from another country.     

 I agree to the terms of the User Agreement and Privacy Policy  

Copyright 2003-2005, Health Insurance , Freedom Benefits Association, P.O. Box 333, Newport NJ 08345 

 

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