Reimbursement Form

1 Reimbursement Form Mail: OneExchange, Box 25181, Lehigh Valley, PA 18002-5181 Fax: (866) 886-0878. Faster, More Convenient, and Green! Skip paper - visit to file electronically. Account Holder SSN (No dashes) Former Employer Name Total Pages Account Holder Last Name First Name Email Address Daytime Phone # (No Dashes). Date of Service Type of Covered Relationship Amount MM/DD/YYYY Coverage Participant Name Requested 01/01/20XX Medical John Doe Spouse $ By signing below, I certify that the information provided on this Reimbursement form is correct and that the expenses for which I am requesting or for which I am providing validation: were incurred for expenses for the covered participant while eligible under the plan on or after its effective date, have not been reimbursed in any other way from any other source, and will not be submitted for future Reimbursement .

2 Account Holder Signature Date To qualify for your Reimbursement Does your document(s) include these items? you must provide a third party Covered Participant Name ( , John Doe). document that includes the Provider Name ( , AARP). information to the right. Please Date of Service ( , 01/01/20XX). CHECK Each Reimbursement Description of Coverage ( , Medical). Qualification item as you complete Proof of Payment them. 400023-160808-FRMPSX-OneExchange Reimbursement Form AC. guide to Requesting Reimbursement To request Reimbursement for your health Requests for future premiums can be care expenses use this form. submitted with this form as long as the future premiums have been paid. Account Holder Information: The Account Holder is usually the retiree or Medicare Part B Premiums must be the surviving spouse.

3 Submitted each month with the use of this form. Reimbursement Information: Complete this section to indicate the Date Out of Pocket Reimbursement of Service; Type of Coverage ( , Documentation: Medical); Covered Participant Name and Relationship to the account holder; and To file a request for an out of pocket Amount Requested, which should be the expense ( , copay, deductible, entire expense you incurred/paid. coinsurance), you must provide proper supporting documentation from a third Certification Requirements: party ( , hospital, doctor, pharmacy) to Carefully read the certification qualify for the Reimbursement . requirements before signing. An Explanation of Benefits (EOB) from Expense Documentation your health insurance carrier will typically include all of the required information.

4 Premium Reimbursement Other documents such as receipts and Documentation: statements are acceptable if they contain To file a request for a health premium all of the above information and DO NOT. ( , medical), you must provide indicate that insurance is pending. If the supporting document(s) from a third receipt is handwritten, it must include party ( , health carrier) to certify the the service provider's signature. request. Documents and Reimbursement A premium statement AND a bank Submission: statement, or a canceled check or Reimbursements cannot be processed premium statement showing the amount without the required information or paid, should include all of the required documents. If you have lost a document, information. contact your doctor, hospital, pharmacy, The payment amount must match the or health insurance carrier to request a amount on the premium statement.

5 Copy. When submitting a request for your Direct Deposit! Why wait for a check? premium Reimbursement , the coverage Expedite your payments by signing up period start date should be used as the for direct deposit today. Refer to your date of service, not the date of payment. Welcome Kit for instructions on how to For Medicare premiums deducted from log into the portal. your Social Security Benefit Payment, please include the "Benefit Award Letter . issued by the Social Security Administration. 400023-160808-FRMPSX-OneExchange Reimbursement Form AC.