How to Submit a Claim for Reimbursement
The following forms and instructions are for traditional (paper) claims only. Visit these links for information on Flex Card and Receipt Requests.
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Instructions for Submitting a Claim to myCafeteriaPlan
- Verify that the expense is eligible for reimbursement by the participant's plan.
- Assemble all supporting documentation.
Canceled checks, credit card receipts, and sales slips are not acceptable as documentation for eligible expenses. Cash register and/or pharmacy receipts are acceptable only when they clearly identify a prescription number or over-the-counter (OTC) item. If an OTC item is not clearly identified, the receipt with the marked or highlighted item should be accompanied by the front box cover of that item. FOR ALL OTHER EXPENSES, supporting documentation must include:
- Provider name and address
- Patient/Dependent name
- Date of Service
- Description of Service
- Amount charged
An Explanation of Benefits (EOB) from an insurance company is acceptable and requires no further documentation.
If receipts are smaller than 8.5x11 inches, copy or tape onto an 8.5x11 inch sheet of paper - do not staple receipts to claim form or each other!
If a pharmacy receipt has been lost: request a filled-prescription history from the pharmacist.
If a medical provider receipt has been lost: request an EOB from the insurance company. No other documentation is required.
For Dependent Care Expenses Only
In addition to the documentation required for all reimbursable expenses, dependent care claim submissions must include:
- Provider's Taxpayer Identification Number (TIN) or Social Security Number (SSN)
- Dependent's age
- Signature of the provider
If the completed claim form is signed by the provider, no other documentation is necessary (the information on the claim form itself is sufficient).
- Copy the supporting documentation and retain the originals.
- Fill out the appropriate claim form.
Login to your account for your customized claim forms or Skip to Fillable Forms.
- Sign the claim form.
Remember, myCafeteriaPlan cannot process a claim submission without the participant's signature as authorization.
- Submit the claim.
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Submit a Traditional (Paper) Claim
There are three ways to submit a claim to myCafeteriaPlan for reimbursement: mail, fax, or e-mail. Follow the Instructions for Submitting a Claim, and send the completed, signed form directly to myCafeteriaPlan by:
| 1) Mail: |
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2) Fax: |
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3) Email: |
myCafeteriaPlan - Claims
432 East Pearl Street
Miamisburg, OH 45342 |
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Fax claim forms to 937.865.6502 |
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Send claim form and copies of supporting documentation as an attachment to
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Contact us at myCafeteriaPlan with questions
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myCafeteriaPlan Fillable Claim Forms
The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion.
Note to Participants: Use only the forms that correspond to your employer's plan as designated in the Summary Plan Description (SPD).
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myCafeteriaPlan Flexible Spending Account (FSA) Worksheets
The following PDF forms contain fill-able fields and automatic calculations, but must be printed in order to be retained as a record. Use these forms to help determine annual election amounts.
Please note Adobe Acrobat® Reader® is needed to view these PDF documents. If you do not already have this program you may click on the icon below for a free download.
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The Tax Savings Calculator can be used to calculate actual tax savings after the annual election is determined.
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