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Indicate the item number to which they pertain. Include a Doctors note when required. Consult the FLEX Handbook for items requiring a Doctor s note. www. pehp.org. The first orthodontia claim must include a copy of the written agreement between you and the orthodontist indicating the total estimated charges and the period of treatment. I also certify that these expenses have not and will not be claimed for reimbursement under any other Flexible Spending Plan insurance plan paid for using your Flex card or claimed as a deduction on a tax return. EMPLOYEE SIGNATURE DATE PEHP APPROVAL Unsigned claims will not be processed. The employer and the Plan Administrator reserve the right to verify to their satisfaction all claimed expenses prior to reimbursement and to refuse any amounts that are not Qualified Health Care Expenses and/or Qualified Dependent Day Care Expenses. Www. pehp.org. The first orthodontia claim must include a copy of the written agreement between you and the orthodontist indicating the total estimated charges and the period of treatment. Please keep a copy of each claim for your records. QUALIFIED HEALTH CARE EXPENSES ITEM NO. NAME OF PROVIDER DATE OF SERVICE EXPENSE DESCRIPTION CLAIM AMOUNT Claims must be for services performed within the Plan Year OR the Plan grace period September 15 TOTAL A FLEX HANDBOOK WITH DETAILED PLAN RULES AND INFORMATION IS AVAILABLE AT www. Please keep a copy of each claim for your records. QUALIFIED HEALTH CARE EXPENSES ITEM NO. NAME OF PROVIDER DATE OF SERVICE EXPENSE DESCRIPTION CLAIM AMOUNT Claims must be for services performed within the Plan Year OR the Plan grace period September 15 TOTAL A FLEX HANDBOOK WITH DETAILED PLAN RULES AND INFORMATION IS AVAILABLE AT www. pehp.org. YOU HAVE 90 DAYS FROM THE END OF THE PLAN YEAR TO FILE CLAIMS FOR THE PRIOR PLAN YEAR. IF YOU RETIRE OR TERMINATE FROM EMPLOYMENT YOU HAVE 60 DAYS TO FILE CLAIMS FOR EXPENSES INCURRED PRIOR TO YOUR TERMINATION DATE. QUALIFIED DEPENDENT DAY CARE EXPENSES PROVIDER TAX ID/SSN Required I the undersigned hereby certify that the expenses for which reimbursement is sought herein are expenses that I the Participant believe in good faith are Qualified Health Care Expenses and/or Qualified Dependent Day Care Expenses during the Plan Year for myself my spouse and/or my legal dependents. Public Employees Health Program FLEX Claims Unified Fire Authority 560 East 200 South Suite 100 Salt Lake City Utah 84102-2004 801-366-7503 TOLL FREE 800-753-7703 FAX 801-366-7772 FLEXIBLE REIMBURSEMENT PROGRAM FLEX CLAIM FORM PLAN YEAR FROM JULY 1 TO JUNE 30 EMPLOYEE INFORMATION EMPLOYEE NAME last first middle initial HOME ADDRESS ID PLAN YEAR CITY/STATE/ZIP DAYTIME PHONE Please complete ALL applicable spaces. Enclose copies of ONE of the following documents for each item claimed An Explanation of Benefits EOB from your insurance company OR a receipt/statement detailing the services provided date of service and the total outof-pocket expense. Indicate the item number to which they pertain* Include a Doctors note when required* Consult the FLEX Handbook for items requiring a Doctor s note.

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