Fillable Dependent-care-claims-form ConnectYourCare Call Center Business Continuity and Contingency Plan

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Dependent-care-claims-form ConnectYourCare Call Center Business Continuity and Contingency Plan

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1
© ConnectYourCare, LLC (1/16)
How to Submit a Claim for Dependent Care Accounts
We offer three easy ways for you to access your Dependent Care Account funds. For fastest results, we
encourage you to submit your claim with CYC Mobile.
For Dependent Care Accounts, you may only receive reimbursements for services already incurred. An expense is
incurred when a service is received, not when a bill is paid. Even though your service provider may require payment
at the beginning of the service period, you cannot request reimbursement until after the service is provided.
Online Claim Submission
1. Collect Documentation: Collect an itemized statement from your dependent care provider containing the
required information (Provider’s Name, Dependent’s Name, Service Period, Payment Amount and Care Being
Provided). Or, ask your provider to complete the Provider Information section on the Dependent Care Account
Claim and Provider Documentation Form (included in this document).
2. Submit Claim and Documentation: Log into your online account at www.connectyourcare.com. Follow the
instructions on the main page to enter a new claim. Enter the requested information about your claim and
continue through the screens to submit the claim and required documentation via fax or upload.
Mobile Claim Submission
1. Collect Documentation: Collect an itemized statement from your dependent care provider containing the
required information (Provider’s Name, Dependent’s Name, Service Period, Payment Amount and Care Being
Provided). Or, as your provider to complete the Provider Information section on the Dependent Care Account
Claim and Provider Documentation Form (included in this document)
2. Submit Claim and Documentation: Log into the CYC Mobile App, available for Android, iOS, and Windows
devices, with the same username and password as your online account. Select “Add a New Claim” and follow
the instructions to enter a claim and submit documentation by taking a picture or uploading a saved image.
Paper Claim Submission
1. Collect Documentation: Ask your provider to complete the Provider Information section on the form as
documentation. Or, collect an itemized statement from your dependent care provider containing the required
information (Provider’s Name, Dependent’s Name, Service Period, Payment Amount and Care Being Provided).
2. Submit Claim and Documentation: Fax the form with receipts and required documentation to (443)-681-4601
When you fax the form and supporting documentation, there is no need to follow up with a hard copy in the mail.
Remember to keep the original claim form and supporting documents for your records.
If you choose to mail your form and documentation instead of faxing, the address is:
Claims Department
P.O. Box 622337
Orlando, FL 32862-2337
2
© ConnectYourCare, LLC (1/16)
Dependent Care Account Claim and Provider Documentation Form
Use this form to submit your claims for reimbursement of eligible dependent care expenses.
You may only receive reimbursements for services already incurred. An expense is incurred when a
service is received, not when a bill is paid. Even though your service provider may require payment at the
beginning of the service period, you cannot request reimbursement until after the service is provided.
Complete all entries on this submission form. Please print or type.
Sign and date this form.
Fax or mail it, along with any additional required documentation, to the claims department. (See
submission instructions below).
Personal Information
Name of Employer
Claim # (if claim has already been entered online)
Employee Name (last name, first name)
Social Security Number
Provider Certification or Documentation Required
You may either have your provider complete this section or you may submit documentation with this form. If submitting
documentation, attach a copy of an itemized statement from your caregiver. The caregiver’s statement must include the
caregiver’s tax ID, dates of service and amount charged. Cancelled checks, credit card receipts or balance forward
statements are not acceptable.
Provider Name: Provider Address: _________
Provider Certifies: • I am a qualified care provider. • I provided care as noted below and charged the amount listed.
Provider Signature Date
Claim Details
Service
Start Date
Service
End Date
Relationship
to Employee
Name of
Provider
Description of Service
Amount
Requested
Total
$
Authorization and Certification
Read carefully: This claim will not be processed without your signature.
I certify that these expenses have been incurred by my eligible dependent. The expenses have not been reimbursed and are not
reimbursable under any other plan, such as an individual policy or my spouse’s or dependent’s plan. I understand that any amount
reimbursed may not be used to claim any federal income tax deduction or credit on my or my spouse’s income tax return. Dependent
care expenses qualify if they are for the care of my children under age 13 or my other dependents who are physically or mentally
incapable of caring for themselves and include anyone I claim on my Federal Income Tax return as a qualified IRS dependent. I
certify these expenses were incurred so that I (and my spouse, if married) can work, look for work or so that my spouse can attend
school full-time.
Employee Signature Date
Submission Instructions
For fastest results, fax to: (443)-681-4601
Or mail to: Claims Department
P.O. Box 622337
Orlando, FL 32862-2337
If you have any questions, please contact Customer Service.
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Dependent-care-claims-form ConnectYourCare Call Center Business Continuity and Contingency Plan

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Completed 12 February 2020

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