Follow the steps to successfully complete the NY DeCAP Claims Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your employee information. Fill in the last name, first name, home address, apartment number (if applicable), city, state, zip code, home or cell phone number, work phone number, email address, social security number, and agency name.
3. Indicate if you have a new address by checking the appropriate box.
4. Proceed to the DeCAP reimbursement requests section. List each dependent for whom you are requesting reimbursement. For each dependent, provide the last name, first name, all dates of service in the format mm/dd/yy, type of service, the total reimbursement amount requested, the provider’s name and address, and the provider’s federal tax ID number or social security number.
5. Ensure you have accounted for all dates of service prior to signing the form.
6. Complete the signature section at the bottom by signing your name or typing it if you cannot sign electronically. Include the date of submission.
7. Double-check that all sections have been filled out completely and accurately, ensuring all necessary signatures are included.
8. Once completed, save your changes. You can download, print, or share the form as needed.

Complete your documents online today to facilitate your DeCAP reimbursement requests.