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Iuoe local 15 welfare fund

44-40 11th Street, Long Island City, New York 11101 Medical Reimbursement Account Request Form
Participant Information – Missing information may delay the processing of your reimbursement. Name
Medical ID Number: YLK

Reg. Number: Email address
In accordance with the Affordable Health Care Act - Section 9003 and I.R.S. Notice 2010-59, effective 01/2011
vitamins and over the counter drugs are not reimbursable without a prescription from your physician. For a
listing of allowable reimbursable expenses, please see reverse side.
Only completed forms that are accompanied with appropriate detailed documentation for claims incurred on or
after July 1, 2008 can be reimbursed.

Date(s) Expense
Products/service Provider
Person Receiving
Receipt Attached
incurred or range
Feel free to add all expenses for
of dates
a Plan Type together as one
Code Types: [1] Medical [2] Dental [3] Optical [4] RX [5] Medical Copay [6] RX Copay [7] Premium Payment Participant Certification To the best of my knowledge and belief, my statements in this form are complete and true. I certify that the reimbursement requests submitted are IRS eligible expenses and that I have not been previously reimbursed for these expenses nor am I seeking reimbursement for these expenses from insurance or any other source. I also understand that the Welfare Fund, its agents or employees, will not be held liable if I submit non –IRS eligible expenses for reimbursement. I authorize a deduction in my account in the amount of the reimbursement. I have received the services described above on the dates indicated, and the expenses are my “out-of-pocket” expenses that qualify as valid expenses under the Plan. _____________________________________________________________________ ________________________________ Participant Signature What is a Qualified Medical Expense?

The Internal Revenue Service has approved the following qualified expenses as reimbursable
Medical equipment for treatment of medical condition Allergy products must be submitted with a
physician prescription in order to obtain
Medical supplies that relate to an existing medical Aspirin must be submitted with a physician
prescription in order to obtain
Birth control must be submitted with a
physician prescription in order to obtain
Occlusal guards to prevent teeth grinding reimbursement.
Co-insurance payments associated with medical, dental Condoms and spermicides must be
Over-the-counter medicine must be
submitted with a physician prescription in
submitted with a physician prescription in
order to obtain reimbursement.
order to obtain reimbursement.
Contraceptives must be submitted with a
physician prescription in order to obtain
Co-payments associated with medical, dental, vision and Counseling for treatment of a medical condition Deductible payments associated with medical, dental, Smoking cessation drugs, gum or patches
must be submitted with a physician
prescription in order to obtain
Fertility treatment (for participant, spouse, or dependent) reimbursement.
Guide dog training and care of for visually, hearing or other physically impaired person. (Proof required) Student health fees (for medical services) Therapy (for treatment of a medical condition) Infertility treatment (for participant, spouse, or Vitamins must be submitted with a physician
Insurance Premiums – only for medical insurance prescription in order to obtain
Wigs as advised by a physician for a medical condition Learning disability treatments Long-term care services (certain conditions apply)


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