6/12
P. O. Box 4346
Miss
oula, MT 59806
DAYCARE REIMBURSEMENT REQUEST
To send scanned claims, or for additional forms, go to:
www
.allegianceflexadvantage.com
FAX: 406-523-3149 or toll-free 877-424-3539 PHONE: toll-free 877-424-3570
Please print legibly in black or blue ink.
Employer Name: __________________________ Total # of Pages Submitted: _____
Employee Name: _________________________ Attention: ____________________________
Participant ID: ____________________________ Comments: ___________________________
(Social Security Number or, if assigned, Allegiance ID)
You may check the status of your claim, within 48 hours, by logging in to your account at
www.allegianceflexadvantage.com. If you have not received reimbursement within two weeks,
please contact an Allegiance representative at 877-424-3570.
If you would like future payments directly deposited into your bank account, include a voided
check with this form or sign up on the Allegiance website.
PLEASE SEE REVERSE FOR INSTRUCTIONS. Use one service line for each different provider. If these expenses are
equivalent each month, you may use our convenient daycare reimbursement contract available on the website.
SERVICE DATES FEES INDIVIDUALS IN CARE PROVIDER PROVIDER SIGNATURE
(mm/dd/yy) (if bill/receipt not attached)
_________ to _________ $_________ ____________________ Name_______________________ _________________________
____________________ Tax ID ______________________ _________________________
_________ to _________ $_________ ____________________ Name_______________________ _________________________
____________________ Tax ID ______________________ _________________________
_________ to _________ $_________ ____________________ Name_______________________ _________________________
____________________ Tax ID ______________________ _________________________
IF YOUR PROVIDER DOES NOT SIGN THE CLAIM FORM, PLEASE ATTACH A STATEMENT OF YOUR ACCOUNT, A BILL, OR A
RECEIPT FROM YOUR PROVIDER.
I c
ertify that the services described on this claim form were necessary for my employment or the employment or education of my spouse. The services
were provided for my qualified dependents. I further certify that the dates and fees are true and that I have not sought reimbursement elsewhere for
these expenses.
Signature (required): ________________________________________ Date: ____________________
□ Check here if your address has changed. New address: _____________________________________
**Please inform your employer if your address has changed.
_____________________________________
