My signature below affirms that the expenses listed in the attached provider receipt were incurred by me or my eligible family members.
Expenses must be submitted within the calendar year the services were provided and no later than March 1st of the following year.
Preventive reimbursement payments will be valid for 60 days.
Lost or stolen checks can be reissued 60 days after original issue date.
Reimbursed expenses cannot be claimed as credits or deductions on your personal income tax.
Reimbursement requests for eligible preventive services are only accepted from providers based in the United States, Canada, and Mexico. If the services were rendered by a provider outside the United States, you may be asked to provide the following items: a copy of a financial statement showing the transaction came from an account under your name and an itemized receipt of the services you received.