Name:
SSN: (last four digits)
Address: Email :
Provider's Name & Address Service Provided
Patient's Name Amount billed
Date of Service
Date
of Service
Amount
From To
Med & Dep Trad Version 06/07
*** Credit card receipts are not acceptable ***
To contact Customer Service, call 800.865.6543
Access your account information 24 hours a day, seven days a week on our web site: www.myCafeteriaPlan.com
READ CAREFULLY
Total Unreimbursed Medical Expenses
The above is a true and accurate statement of all expenses incurred by my eligible dependents or me on the date(s) indicated, and were incurred while I was covered under the
Flexible Spending Account(s). Supporting documentation from my service provider(s) for all expenses are attached to this voucher. I understand that I cannot claim any reimbursed
expenses on my income tax return, and that I may be liable for payment of all related taxes including Federal, State, or City income tax and any associated penalties on the amounts
paid for any expense improperly claimed under the provisions of the Flexible Spending Account(s).
Participant Signature Date
Provider Social Security # or Taxpayer ID # Signature of Dependent Care Provider
Child's Name
Service Date
UNREIMBURSED MEDICAL EXPENSES (Attach supporting documentation)
Person for Whom Expense
was Incurred
Name of Service
Provider
Do your receipts include all
of
the following?
Check here if address has changed
City, State, Zip: Day Phone:
EMPLOYEE INFORMATION (Please Print)
I certify that I have provided dependent care services as described above. I have charged $____________ for the services I
rendered on the dates listed above.
Total Dependent Care Expenses
Name & Address of Service Provider Amount
Description of Services
Mail To: myCafeteriaPlan, 432 East Pearl St., Miamisburg, OH 45342
Fax To: 937.865.6502 Email To: claims@myCafeteriaPlan.com
Age
DEPENDENT DAYCARE EXPENSES (Attach supporting documentation if Provider does not sign form )
Supporting documentation for dependent care expenses is required only if provider does not sign this form. Otherwise, documentation must
include the provider’s name, address, Tax I.D.#, dependent's name, dates of service and amount charged.
If Faxing
# of Pages
University of Dayton
Medical and Dependent Daycare
Reimbursement Claim Form
