You may then apply for reimbursement of the expenses not covered in part or in full. Keep your original bills and proofs of payments for your records. Certification To the best of my knowledge, the above information is accurate. I am requesting payment for eligible health care expenses incurred during the plan year and not eligible for payment under any other benefit plan. I will not deduct these expenses on my individual federal tax return.
Qualification includes meeting the definition of dependent under the plan.
After filling in the appropriate information, sign and date the form, and make a copy for your records.