Fillable 2019EmeritiReimbursementForm1 Emeriti Retirement Health: Reimbursement Benefit Claim Form

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2019EmeritiReimbursementForm1 Emeriti Retirement Health: Reimbursement Benefit Claim Form

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Emeriti®
Retirement Health
Emeriti Retiremen Health
Reimbursement Benefit Claim Form
Be sure to provide all requested information, substantiate your claim(s) by providing proof of payment, and
sign the form. If your claim is denied, you will be informed by mail. You will be provided the reason for a
denial and an opportunity to appeal or resubmit your claim.
If you are using money from the Executive Healthcare Benefit (Grantor Trust), please keep in mind that you
can only be reimbursed for fully-insured medical insurance premiums.
IMPORTANT STEP BEFORE YOU SUBMIT A CLAIM:
Reimbursements are paid only with money in the TIAA-CREF Money Market Mutual Fund.
• To check your Emeriti health account balance and transfer!money into!the TIAA-CREF
Money!Market Mutual Fund (or set-up monthly transfers), please call!1-866-EMERITI (1-866-363-7484)
and press option #3. Keep in mind your employer contributions are defaulted into an age-appropriate
TIAA-CREF Lifecycle Mutual Fund, so you'll need to move money to the TIAA-CREF Money Market
Mutual Fund in order to be reimbursed.
• You may also log in to your TIAA account at!tiaa.org and!follow the instructions.
1.Participant'(Account'Holder) Information
Name:____________________________________________________________________________________
Institution:_________________________________________________________________________________
Social Security Number: _______ _____ _________ Street
Address:_________________________________________________________________________________
City: ________________ State: ____ Zip: ________ _____
Daytime Phone: ____ ___ _____ Ext:!________
2. Participant'Eligibility
I am eligible to receive reimbursement benefits because:
o I no longer work for the employer sponsoring the Plan
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®
Retirement Health
3. List of Qualified#Medical Expenses. Enter each QME!claim in the chart below. If additional space is needed, please provide all requested
informa tio n from the grid below on a sep ara t e sheet of pap e r.
Service/Product Recipient (i.e.-Patient)
Date of
Service/Purchase
Name
SSN
Relationship to Participant*
(must check one b o x)
Service/Product
Provider's Name
(e.g.#Doctor,#
Pharmacy, Clinic)
Type#of Expense
(must check one b o x)
Requested
Reimbursement
Amount
o Set up!as
recurring
claim
o Myself
o Spouse
o Dependent Child
o Dependent Domestic Partner
o Non-Dependent Domestic
Partner**
o Dependent Relative
o Surviving Spouse
o Surviving Child
o Rx Drugs
o Medical Care
o Dental Care
o Vision Care
o Insurance Premiu m
o Other
o Set up!as
recurring
claim
o Myself
o Spouse
o Dependent Child
o Dependent Domestic Partner
o Non-Dependent Domestic
Partner**
o Dependent Relative
o Surviving Spouse
o Surviving Child
o Rx Drugs
o Medical Care
o Dental Care
o Vision Care
o Insurance Premiu m
o Other
o Set up as
recurring
claim
o Myself
o Spouse
o Dependent Child
o Dependent Domestic Partner
o Non-Dependent Domestic
Partner**
o Dependent Relative
o Surviving Spouse
o Surviving Child
o Rx Drugs
o Medical Care
o Dental Care
o Vision Care
o Insurance Premiu m
o Other
* Please!refe t th separat Frequentl Aske Questions document regarding!who qualifies!a a eligible!“Plan!Dependent.”
** Please!not tha reimbursed!claims!fo non-indpenden domestic!partner ar taxabl distributions!from th Plan. Please!refe to!Frequently!Aske Questions for!details.!
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®
Retirement Health
4. Proof of Payment
You must submit proof of payment for each Qualified!Medical!Expense, which may be (i) an Rx label ,!(ii)!an
insurance!billing!statement,!(iii)!an Explanation of Benefits (EOB),!or (iv)!an itemized!bill!for medical!services
rendered.! Please refer to th Instructions&an Additional Information&below&fo details.
5. Certification and Signature
B m signatur belo hereb certif and/o acknowledge&th foll owing:&
1) The Qualified!Medical Expenses identified!above were!incurred by me and/or my eligible!Plan Dependent(s). Any prescribed
medication or allowable medical supply!requested!above was purchased for me and/or my eligible!Plan Dependent(s) and was not
purchased!for general good health.
2) I am solely!responsible for the correct designation!of my eligible!Plan Dependents, and I have!made suc designation(s) herein!in
compliance!with!the terms of my Plan!and the Summary Plan Description. I understand that if!I make such designation
incorrectly, either by error or intent,!that I will be responsible for refunding to the Plan!any associated!ineligible QME
reimbursements I received!as!soon as practicable!following!the discovery of such incorrect designation of a Plan Dependent.
3) To the extent I am submitting!a request for the reimbursement of an expense incurred by my dependent domestic partner, as
indicated!by me in Section!3 above, I certify that such individual maintains!residence in my home as his!or her!principal place
of abode and is a member of my household. Further, I certify that such individual receives over half!of his or her support!from
me,!and!is! covered under the terms of my Plan.
4) To the extent I am submitting!a request for the reimbursement of an expense incurred by my non-independent domestic
partner, as indicated!by me in Section!3 above, I certify that such individual maintains!residence!in!my home as his or her
principal!place!of abode and is a member of my household,!and is!covered under the terms of my Plan.
5) To the extent I am submitting!a request for the reimbursement of an expense incurred by a dependent relative, as indicated by! me in
Section 3 above, I certify that such individual (a)!receives!over half of his!or her support from me,!and (b) is either
(i) my child or a descendant of a child,!sibling, step sibling,!parent, ancest or!of my parent, stepparent, aunt,!uncle, niece, nephew,!son-
in-law, daughter-in-law, father-in-law,!mother-in-law, brother-in-law,!sister-in-law, irrespective!of whether
living!in my home, or (ii)!and individual!who maintains!residence!in!my home as his or her principal! place!of abode!and is!a member
of my household,!and!is covered under the terms of my Plan.
6) If I receive!a reimbursement benefit for a claim!incurred by a Plan Dependent who is not eligible!to be treated as my dependent
under the Internal Revenue Code (such as!a non-independent domestic!partner), I understand that!such reimbursement will
be taxable!under the Internal Revenue Code.
7) These expenses!for which I a seeking!reimbursement have not previously been reimburs ed!to me (or a Plan!Dependent) by
any other plan! covering health!benefits,!nor will I (or a Plan!Dependent) seek such reimbursement.
8) I am!not currently!covered under a Flexible!Spending Arrangement (a “FSA”) under Internal Revenue Code Section 125 (a
“cafeteria plan”), or if!I am covered under a FSA for the applicable!period, I have exhausted my maximum annual coverage for the!year
in which!the expenses were incurred.
9) I am not currently!enrolled!in!a Health!Savings!Account (an “HSA”), or if!I am enrolled!in an HSA, I have first!satisfied!the high
deductible health!plan’s annua l!deductible for the year for which the expense was incurred.
10) To the extent my claim!is for the reimbursement!of insurance premiums, if!I (or!an eligible Plan!Dependent) receive(s) a full or
partial refund of a reimbursed premium from any medical provider!or insurance company, after!being reimbursed!by my Plan, I
am obligated! to return the refunded!amount to my Emeriti Health!Account.
11) I further certify!that I understand!that any person!who,!knowingly and with!intent to defraud!or deceive,!files a claim
containing!any!materially!false,!incomplete or misleading information!may be prosecuted under state law!and be subject to
civil fines!and!criminal!penalties.! I hold Savitz RPS, its affiliated companies, officers, and employees, Emeriti!Retirement!Health
Solutions, its!officers and employees, TIAA Trust!Company, its affiliated!companies, officers!and!employees, and my Plan
harmless for!payment of any ineligible expenses!presented!in such!a manner under!the terms and conditions!of the Emeriti
Reimbursement Benefit.
Signature: ______________________________________ Date: _____________
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Emeriti®
Retirement Health
6. Legal Representative
If this Claim Form is b eing completed!by a!legal representative!of the!Participant (e.g., guardian, individual with power!
of attorney, executor),!pleas submit!appropriate!proo for basis!of authority!with this!claim.
Basis of#Authority ___________________________________________________________________________
Name:!_____________________________________________________________________________________
Address ___________________________________________________________________________________
Phon / Email:!__________________________________________________________________________
7. Preferred#reimbursement#method for this and all future claims
You need only make a!selection the first time you submit a!claim.
o Check
o Direct Deposit (please fill out information below)
Name!of Bank:____________________ ______________________________________#
Accoun Type (Checkin or Savings)__________________________________________
Routing!Number: _____________________________________________________
Account Number:________________________________________________________!
8. Checklist
Before subm itting this form, did you...#
1. Include!proof of payment for all claim bein submitted,!including!doctor’s!prescription for over-the-
counter medications?
2. Sign!and!certify the Form i Section!5?
3. Fully complete each column!in!Section!3?
4. Chec the available!balance!in your TIAA-CREF Mone Market Mutual Fun within!your Emeriti health!
account, and!transfe funds i necessary t cove th cos o reimbursement?
5. Retain copy!of this!Form and all supporting documentation!in th event that!your claim requires!
additional!information!for processing?
6. Include!all pages!of the reimbursement benefit claim form with!your submission?!
9. Choose how to submit your claim
Your Claim Form and!supporting!documen ts can!be submitted!by either fax, mail or online.
Fax
215-563-9943
Mail
CBIZ RPS
3000 Chestnut Street #8569
Philadelphia P 19104-9998
Online
MyEmeritiBenefits.org
Chec the
statu o reimbursements,
an electronically!submit claims
4
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2019EmeritiReimbursementForm1 Emeriti Retirement Health: Reimbursement Benefit Claim Form

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Completed 12 February 2020

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