Fax: 877-641-5956
Phone: 501-941-5956
Cabot, AR 72023
P.O. Box 1513
Medical Claim form
First Name
Last Name:
Check here if new address
Documentation/Receipts for each expense must
be provided.
Please Itemize each expense on form provided,
if you have more expenses than form allows
please attach separate form.
Date of Service Provider Name Description of Service Expense Amount
I certify that the statement and information on this claim form are accurate and true.
I also certify that I am claiming reimbursement for only eligible expenses incurred during the plan year and are for eligible participants.
I certify that these expenses have not been or will not be reimbursed from any other source.
I assume all liability for taxes and penalties out of any disallowed contribution/reimbursement
Total Expense
Signature: Date:
Mail claims to: P.O. Box 1513, Cabot AR 72023; Fax claims to: 877-641-5956; or E-mail claims to:
For questions regarding your claims please call: 501-941-5956
Print Form
click to sign
click to edit