RHSEligibilityFormFRM080-003--201106-C325 Full Names of Spouse Social Security Birthdate & Eligible Dependents Number Month Day Year Relationship • Complete this form once you become eligible to receive benefits in your employer’s RHS Plan. Please print legibly in blue or black ink.• Read instructions on the back before completing this form.• Return this form to: VantageCare RHS Plan, c/o Meritain Health, Inc., P.O. Box 30136, Lansing, MI 48909-7611.Important Note: Your employer must also submit your eligibility information into the EZLink system to establish your benefit eligibility. Please confirm that this notification has occurred prior to submitting claims to Meritain Health, Inc. PLEASE RETAIN A COPY FOR YOUR RECORDS 1 Participant Information Employer Plan Number ___ ___ ___ ___ ___ ___ Employer Name State _____________________________________________________________________________________ _________Participant Name (Last, Full First and Full Middle)Gender p Female p Male Social Security Number ____ ____ ____ - ____ ____ - ____ ____ ____ ____ Mailing Address Street ____________________________________________________________City ______________________________________________________________ State _____________________________ Zip Code _____________________Date of Birth ____ ____/____ ____/____ ____ ____ ____ Area Code Home Phone Number (____ ____ ____) ____ ____ ____ - ____ ____ ____ ____ Work Phone Number Area Code (____ ____ ____) ____ ____ ____ - ____ ____ ____ ____Marital Status p Married p Single 2 Spouse and Dependent Information (Complete this section if you have a spouse and/or eligible dependents. See instructions.)3 Participant Signature I certify that the information provided on this form is accurate and that all listed dependents are eligible to receive benefits under the RHS Plan (see instructions):_________________________________________________________ ______________________________Participant Signature Date Month Day Year ____________________________________________________________________VANTAGECARE RETIREm ENT HEALTH SAVINGS (RHS) PLAN E m PLOYEE BENEFIT ELIGIBILITY FOR m VantageCare Retirement Health Savings (RHS) Plan, c/o Meritain Health, Inc., P.O. Box 30136, Lansing, MI 48909-7611 • 1-888-587-9441 • Fax: 888-665-8495
Once your employer has indicated you are eligible for benefits and you submit this completed form, you will be able to request payment for benefits covered by your employer’s RHS plan. This form is used by the claims administrator (Meritain Health, Inc.) to set up your account and process claims.In order for us to efficiently process your benefits, you must fully complete this form and submit it to Meritain Health, Inc. Please be sure to keep a copy of all forms and documentation you submit for your records. Accuracy and completeness of the information you submit will expedite your claims. After a claim you have submitted has been processed, always review your Explanation of Benefits from Meritain Health, Inc. to confirm the accuracy of your benefit eligibility and enrollment information. If you discover a discrepancy, contact Meritain Health, Inc. at 1-888-587-9441 as soon as possible.INSTRUCTIONS :1. Participant Information Please complete this section carefully. The information will be used to set up your account for benefit payments. You will receive your reimbursements and Explanations of Benefits at the address you list. The employer plan number is available from your employer or ICMA-RC’s Investor Services staff at 1-800-669-7400.2. Spouse and Dependent Information An eligible dependent is (a) the Participant’s lawful spouse, (b) the Participant’s child under the age of 27, as defined by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010-38, or (c) any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004-79. In general, dependents consist of your spouse* and those who meet each of the following three criteria:A. The person is related to you OR lived with you for the entire year as a member of your household; and B. The person was a U.S. citizen or resident (or resident of Canada or Mexico) for some part of the calendar year; and C. You provided over half of the person’s total support for the year. See IRS Publication 502, Medical and Dental Expenses, for more information.For your spouse and each dependent, please indicate the full name, Social Security Number, birth date and relationship to you.* Important information for California Participants: In order to receive a tax free reimbursement under Federal guidelines for a domestic partner, they must qualify as an IRS Code 152 dependent. Section 1.105-2 of the Income Tax Regulations provides that only amounts that are paid specifically to reimburse the taxpayer for expenses incurred by the taxpayer, spouse or dependents for the prescribed medical care are excludable from gross income. No benefits are paid on behalf of a domestic partner unless the domestic partner meets the definition of dependent as described in the IRS Code 152.If you need to add or delete eligible spouse or dependents, contact Meritain Health, Inc. at 1-888-587-9441.3. Participant’s Signature Once you have completed this form, sign it, retain a copy for your records and submit it to Meritain Health, Inc.Your signature on the form certifies that all information provided is accurate, and that all dependents meet the IRS criteria outlined in the instructions for Section 2.Please Note: Your employer must also submit your benefit eligibility date to ICMA-RC via EZLink before benefits can be paid. Check with your employer to be sure this notification has occurred prior to submitting claims to Meritain Health, Inc.RHS PLAN E m PLOYEE BENEFIT ELIGIBILITY FOR m INSTRUCTIONS VantageCare Retirement Health Savings (RHS) Plan, c/o Meritain Health, Inc., P.O. Box 30136, Lansing, MI 48909-7611 • 1-888-587-9441 • Fax: 888-665-8495