CSEA 262 Health Reimbursement Form

CSEA 262 Health Reimbursement Form

Unit members in paid status in a less than 50% assignment shall receive the annual benefit amount of $1,200 deposited into a District-managed CSEA 262 health reimbursement account.

Unit members may submit receipts for reimbursement of health expenses incurred between October 1 and September 30, or beginning their first date of eligible permanent employment, whichever occurred last.

Submissions received after the 15th of the month will be reviewed and processed the following month.

Submissions are reviewed continuously; however, status updates may take up to 10 business days from the submission date. Every effort is made to respond to your submission by the 15th of each month.

Employee ID #*

First Name*

Last Name*

Mt. SAC Email*

Health Reimbursement Eligible Expenses

You can use your funds to pay for a wide variety of health care products and services for you, your spouse, and your dependents. The IRS determines which expenses can be reimbursed by an Flexible Spending Account (FSA).

For a list of eligible expenses please visit: https://americanfidelity.com/claims/fsa-hsa-eligibility-list/.

Please submit receipts and other supporting documentation related to your expenses and claims. Human Resources may request additional itemized receipts to verify the eligibility of your expenses.

Who is the service for?*

Self (Employee)

Spouse/Domestic Partner

Dependent Child (under age 26)

Age of Dependent Child*

What date did you receive service/treatment or make an eligible purchase?*

Please submit one request form per date.

Please indicate whether this is related to a medical, dental, or vision expense.*

Select

Please indicate the type of service/treatment received or the eligible product purchased.*

You may select more than one option.

Select or enter value

How much did you pay out of pocket?*

Receipt Requirements

You must have a receipt or an explanation of benefits from your insurance carrier for each health care claim you submit against your account. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

To expedite processing, please ensure the five pieces of information below are included on the official receipt:

Patient's Name – the name of the person who received the service or for whom the item was purchased. (For retail store purchases, this information may be excluded.)

Provider's Name – the provider that delivered the service or the merchant where the item was purchased.

Date of Service – the date when services were provided or the item was purchased.

Type of Service – a detailed description of the service provided or item purchased. (A pharmacy prescription receipt is sufficient for prescriptions.)

Expense Amount – the amount paid for the service or product and/or the portion that is not reimbursed through your insurance carrier.

File Upload*

Submissions received after the 15th of the month will be reviewed and processed the following month.

Drag and drop files here or

Student Health Center Access for Less Than 50% Unit Members

Unit members in paid status in a less than 50% assignment shall be permitted access to the campus Student Health Center for basic medical services, subject to the limitations and capabilities of the facility and staff.

The cost of services provided by the Student Health Center shall be charged against the unit member’s medical reimbursement account. Costs in excess of the funds available in the unit member’s medical reimbursement account will be the responsibility of the unit member.

For more information, please visit www.mtsac.edu/healthcenter.

I authorize the above expenses to be reimbursed from my account balance. To the best of my knowledge, my statements on this form are true and complete. I certify that either I, my spouse, my tax dependent, or my adult child who will be under the age of 27 as of the end of the calendar year has received the services described above on the dates indicated and that the expenses qualify as valid “medical care expenses” as defined by Internal Revenue Code Section 213(d). I certify that these expenses have not been reimbursed under this or any other health plan, and I will not seek reimbursement under any other health plan. Furthermore, I understand that I may be asked to provide additional documentation or additional details relating to an expense and any and all medical information included for reimbursement will be reviewed by Human Resources.*

Send me a copy of my responses

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