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RHSReimbursementRequestForm• Complete this form and send with supporting documentation to VantageCare RHS Plan, c/o Meritain Health, Inc., P.O. Box 30136, Lansing, MI 48909-7611. You may also fax this request with supporting documentation to 888-665-8495 for processing.• Each form of documentation must contain the date(s) of service, provider name, provider address, description of treatment, service or supply, amount charged, insurance payments, as well as the name of the claimant. Supporting documentation may consist of: Itemized Bills, Explanation of Benefits, Premium Notices, Itemized Receipts.PLEASE NOTE: SIGNATURE IS REQUIRED FOR PROCESSING. Do not submit claims for charges eligible under your insurance or Medicare. A medical care expense may not be reimbursed from a FSA if the expense has been reimbursed or is reimbursable under any other accident or health plan. If a medical care expense is eligible for coverage by both an HRA and a health FSA, amounts available under an HRA must be exhausted before reimbursement may be made from a health FSA. This requirement does not apply to medical care expenses which are reimbursed from a health FSA but are not reimbursable by an HRA. In no case may a participant be reimbursed for the same medical care expense by both an HRA and a health FSA. Do not submit claims for services provided prior to your benefit eligibility date. Claims are processed upon receipt of documents in good order.Note to Survivor: Upon the death of the RHS Plan Participant, all claims for decedent’s qualified medical expenses should be submitted using the VantageCare Retirement Health Savings Plan Benefits Reimbursement Request Form, prior to submitting the VantageCare Retirement Health Savings Plan Decedent Information Form.Employer Plan Number Employer Name State Participant Name (Last, First and Middle Initial)Social Security Number – – Daytime Phone Number ( ) – A re A C ode Address S treet C ity S t A te Z i P NOTE: If this is a new address, please contact ICMA-RC at 800-669-7400 to update your address. Your check will be mailed to the address on file with ICMA-RC.PLEASE RETAIN A COPY FOR YOUR RECORDS (for recurring expenses see page 2)Summary of Healthcare Expenses READ CAREFULLY AND SIGN BELOW FOR PROCESSING.The undersigned certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred by the participant, the participant’s spouse, or the participant’s eligible dependents while the undersigned was eligible to receive benefits under the RHS Plan. The undersigned also certifies as follows:• The medical expenses have not been reimbursed and are not reimbursable under any other health/dental plan or Medicare.• The undersigned is responsible for requesting cessation of automated reimbursement of recurring expenses when the expense is no longer being incurred, and will retain sufficient documentation for all recurring expenses. Meritain Health, Inc. reserves the right to periodically request documentation for all automated payment requests.The undersigned understands that he/she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim. The undersigned understands that he/she will be liable for payment of all related taxes including Federal, state or local income tax on amounts paid from the Plan for non-qualifying expenses. Participant Signature Date FRM080-002-0812-5876-C1333 VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN BENEFITS REIMBURSEMENT REQUEST FORM - Page 1 of 2 Part A: Plan and Participant Information Part B: Request for Reimbursement of Non-Recurring Expenses Use this section to request a reimbursement of non-recurring expenses (e.g., co-payments, medications, out-of-pocket expenses).Incurred Date*Applicant’s Full Name (last, first, middle initial)Provider (e.g. doctor name/pharmacy name)Claim for (self, spouse, dependent child, other dependent)Description of Service Amount to be Reimbursed $$$* Incurred date is the date of service, not the billing or payment date.Total reimbursement request:$ Participant Name (Last, First and Middle Initial)Social Security Number – – VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN BENEFITS REIMBURSEMENT REQUEST FORM - Page 2 of 2 Part B: Request for Reimbursement of Recurring Expenses 1. B E g IN recurring reimbursement of $ Beginning Date: Insert date you wish payments to begin / / (mm /dd /yyyy ) Frequency (Check one): Annual Quarterly Monthly Ending Date: Insert date of last payment / / (mm /dd /yyyy )2. Ch AN g E recurring payment amount from $ to $ Effective date of change / / (mm /dd /yyyy )3. E ND recurring payment of $ Ending Date: Insert date of last payment / / (mm /dd /yyyy )Note: Payments will continue until your account is depleted, unless an ending date is provided. Any changes to your payment must be received by Meritain Health at least 10 business days prior to next payment. Otherwise the change will take effect on the next scheduled reimbursement. READ CAREFULLY AND SIGN BELOW FOR PROCESSING.The undersigned certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred by the participant, the participant’s spouse, or the participant’s eligible dependents while the undersigned was eligible to receive benefits under the RHS Plan. The undersigned also certifies as follows:• The medical expenses have not been reimbursed and are not reimbursable under any other health/dental plan or Medicare.• The undersigned is responsible for requesting cessation of automated reimbursement of recurring expenses when the expense is no longer being incurred, and will retain sufficient documentation for all recurring expenses. Meritain Health, Inc. reserves the right to periodically request documentation for all automated payment requests.The undersigned understands that he/she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim. The undersigned understands that he/she will be liable for payment of all related taxes including Federal, state or local income tax on amounts paid from the Plan for non-qualifying expenses. Participant Signature Date PLEASE RETAIN A COPY FOR YOUR RECORDS Send completed form to: VantageCare Retirement Health Savings (RHS) Plan, c/o Meritain Health, Inc., P.O. Box 30136, Lansing, MI 48909-7611 • 888-587-9441 Use this section to request automated reimbursement of recurring expenses (e.g. insurance premiums). Note: Payment must be made to the account holder. Payment will not be made directly to an insurance company or other third party.You are responsible for ensuring that automated reimbursements are for qualifying medical expenses. You are also responsible for ensuring that automated reimbursements are stopped if you are no longer incurring the expense(s). You must provide documentation of the recurring expense with this request, and you must retain sufficient documentation for all recurring expenses. Supporting documentation must show that the premium is paid after taxes and include the following: (i) Insurance Carrier; (ii) Type of Insurance; (iii) Policy Holder’s Name; (iv) Amount; and (v) Coverage Period. Meritain Health, Inc. reserves the right to periodically request documentation for all automated payment requests.