Fillable Cdphp Reimbursement CDPHP CO-PAY REIMBURSEMENT FORM

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Cdphp Reimbursement CDPHP CO-PAY REIMBURSEMENT FORM

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HUDSON VALLEY COMMUNITY COLLEGE
CDPHP CO-PAY REIMBURSEMENT FORM
Subscriber Name:
Social Security #:
Member Name:
Date Submitted:
Contact Information:
(If different from subscriber)
(Phone or email)
Please attach receipts that show the co-pay amounts, provider and dates of service.
Cash register receipts that do not indicate what the payment was for are not acceptable.
Your co-pay reimbursement must total a minimum of $20 before submissions can be made.
Submit this form and all attachments to:
Capital Benefits Consulting
385 Jordan Road
Troy, NY 12180
(518) 283-6650
Email: mrobert@capben.com
(Maria Robert)
Capital Benefits will verify coverage and calculate amounts owed.
Payment will be made by HVCC on college check stock.
Checks will be processed once each month.
Please remember when paying with your Flexible Spending Account, you may only
submit for $15 of the $25 co‐payment. The remaining $10 is processed through the co‐
pay reimbursement program.
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Cdphp Reimbursement CDPHP CO-PAY REIMBURSEMENT FORM

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Completed 15 November 2019

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