Get Cigna Choice Fund Dependent Care Reimbursement Request Form

Completing the Cigna Choice Fund Dependent Care Reimbursement Request Form is essential for users seeking reimbursement for dependent care expenses. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently online, ensuring all necessary information is provided for prompt processing.

Follow the steps to complete your reimbursement request online.

1. Press the ‘Get Form’ button to access the Cigna Choice Fund Dependent Care Reimbursement Request Form and open it in the editing interface.
2. Fill out the Employee Information section (A). Provide your Cigna ID number or social security number, last name, first name, middle initial, date of birth, mailing address, daytime telephone number, email address, city, state, zip code, employer name, and account number(s). Ensure that all required fields, marked with an asterisk (*), are completed.
3. In Section B, titled Information About the People Receiving Care, enter the name of the person receiving care. If you are submitting expenses for more than one individual, write 'Family'.
4. In Section C, Day Care Expenses, list the type of service (e.g., day care, meals, field trips, overnight camps) and description of expenses for each relevant item. Provide the date(s) of service, the amount incurred, the caregiver's name, address, city, state, and zip code. Make sure you only include covered expenses as specified in the additional information provided on the form.
5. If you are not submitting itemized receipts, obtain the caregiver’s signature in box 21, which is mandatory under this condition. If multiple caregivers are involved, utilize separate forms for each.
6. In the Certification section (D), read the certification statement carefully and ensure that it accurately reflects your claim for reimbursement. Sign and date the document in box 22 to affirm that all information is true and complete. Note that an unsigned form will be regarded as incomplete and may not lead to reimbursement.
7. After completing the form, save your changes. You may then download, print, or share the form as necessary, ensuring you maintain a copy for your records.

Complete your Cigna Choice Fund Dependent Care Reimbursement Request Form online and ensure timely reimbursement!