How to submit a claim for for recurring medical expenses. **All sections of the claim form must be completed in order to receive reimbursement, including signature and date.** Claim Form Section A: Declaration of Services Enter the start and end date of the services provided Complete the provider’s charges (you will need to include the … More >>
Authorize Discussions with Others HIPAA regulations prevent DataPath from sharing any details about your account, claim, reimbursement, debit card, etc. with anyone besides yourself unless we have a signed Authorization for Release of Information on file that names the specific person. Submit this form if you want to authorize other people, such as your spouse, … More >>
This Salary Reduction Agreement (SRA) authorizes your employer to reduce your salary by the indicated amount shown below for the exclusive purpose of facilitating a contribution to your Health Savings Account. Do not send contributions with this form. By completing this agreement, you are indicating that as of the effective date of your contribution election, … More >>
This form is used to request an HSA Transfer or Rollover from a prior custodian to DataPath Administrative Services. General Information An account transfer, or rollover, is how money or property can be moved into a Health Savings Account (HSA) from a Medical Savings Account (MSA) or existing HSA. The Internal Revenue Code (IRC) limits … More >>
Complete this form to request automatic reimbursement from your Dependent Care Assistance Plan (DCAP) account. Contributions will be reimbursed to you on a per-pay-period basis. By completing this form you will not need to provide continuing documentation. Please complete all fields and include appropriate documentation stating your child will be attending throughout the year or … More >>
Use this form to request that a claim reimbursement be deposited directly into your bank account. Instructions for completing this form: Fill in all fields below Attach voided check (no deposit slips) Sign and date form. If the account is not in your name alone, the other account holder must also sign and date form.
How to Submit a Claim Form All sections of the claim form must be completed in order to receive reimbursement, including signature and date. Claim Form Section 1: Employee Information The following information must be included for each claim: Employee (Participant) Social Security Number Employee Name Employee Address Employee Phone Number Claim Form Section 2: … More >>