Wyoming PDFs

Wyoming PDFs
Homepage >> Fill Your Wyoming Medical Reimbursement Template
Article Guide

The Wyoming Medical Reimbursement form is an essential tool for employees participating in the state’s Flexible Spending Plan, allowing them to seek reimbursement for eligible medical and dependent care expenses. This form requires specific information, including the employee’s agency name, Social Security number, and contact details, as well as detailed claims for reimbursement. It is divided into two main sections: one for medical expenses and another for dependent care costs. Each section mandates the completion of various fields, such as the date of service, provider information, and the total amount requested. To ensure proper processing, claimants must attach relevant documentation, including itemized invoices and explanations of benefits from insurance providers. The form emphasizes the importance of adhering to IRS guidelines, as expenses that are reimbursed cannot be claimed as tax deductions. Additionally, it outlines eligibility criteria for dependent care, specifying the conditions under which expenses can be reimbursed. Overall, this form streamlines the reimbursement process while providing clear instructions to help employees navigate their claims effectively.

Preview - Wyoming Medical Reimbursement Form

MEDICAL REIMBURSEMENT AND

DEPENDENT CARE ACCOUNT CLAIM FORM

STATE OF WYOMING FLEXIBLE SPENDING PLAN

Agency Name

Agency #

Social Security Number

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

Home Address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUEST FOR REIMBURSEMENT FROM THE MEDICAL ACCOUNT

This section must be completed in its entirety

 

Date of

 

 

Patient

Requested

Service Provider Name

Service

 

Name

 

Relationship Age

Amount

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

Total Medical Reimbursement Requested

 

$

REQUEST FOR REIMBURSEMENT FROM THE DEPENDENT DAY CARE ACCOUNT

This section must be completed in its entirety

 

Date of

 

Dependent

Requested

Name & ID# of Provider

Care

Name

Relationship/Age

Amount

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

Total Dependent Care Reimbursement Requested

 

$

Dependent Care Provider Signature (Receipt may be attached in lieu of signature)

Please sign on back page

FOR OFFICE USE ONLY

Date Received

Date Paid

You must attach an explanation of benefits (EOB) for any item covered by any insurance you have.

These services are not allowable under my and/or my spouse’s and/or dependent’s insurance policy for the following reason(s):

ITEMIZED INVOICES AND AN EXPLANATION OF BENEFITS FROM INSURANCE COMPANY MUST BE ATTACHED.

GENERAL

Requests for reimbursement may be submitted at any time. Semi-monthly reimbursement will be made directly to you. Reimbursement checks will be issued two times during the month (see the current reimbursement claims processing schedule).

If you apply for reimbursement of expenses that the IRS later determines to be ineligible, those reimbursements may be taxed as ordinary income and IRS penalties may apply. Similar treatment may apply to overpayment of reimbursed expenses that have already been reimbursed from some other source.

MEDICAL REIMBURSEMENT

Eligible expenses are qualified medical/dental expenses of the employee, spouse, and dependent(s) that are not eligible for reimbursement from any other source. Expenses that are eligible for reimbursement under a health insurance plan should not, for example, be included on this form. A list of typical IRS approved medical/dental expenses is documented in your Flexible Benefit Plan Summary. General information on the Employee Reimbursement Accounts as well as claims status may be obtained by contacting the Employees’ Group Insurance Office at 777-6835 or 1-800-891-9241.

I request reimbursement from the Employee Reimbursement Account(s) for the expenses itemized above. I hereby certify that I have read and understand the guidelines on this form and that these expenses must qualify for reimbursement under the Internal Revenue Code as outlined on the form.

I further certify that these expenses are not eligible for reimbursement from any other source. I also understand that reimbursement expenses cannot be claimed as credits or deductions on my personal tax return.

DEPENDENT DAY CARE REIMBURSEMENT

Expenses to provide care for your eligible dependents may qualify for reimbursement. Eligible dependents include children under age 13, a disabled child, a disabled spouse, or a dependent disabled parent.

To be eligible, you must be working while your dependents receive care. Also, if you are married, your spouse must be:

−A wage earner, or

−A full-time student for at least 5 months during the year, or

−Disabled and unable to provide for his or her own care.

Expenses eligible for reimbursement are those incurred to enable you to be gainfully employed, and include covered charges by:

−Licensed nursery schools and day care centers

−Individual – other than your dependents – who provide care for your children in or outside your home, or for your disabled spouse or dependent parent in your home.

−Housekeepers, maids or cooks in your home, to include their food and lodging in your home, as long as their services are performed for the benefit of your eligible dependent(s).

Under IRS Regulations, qualified individuals can receive a tax credit for dependent care costs. This credit is claimed on your personal tax return. You CANNOT claim the tax credit for any dependent care costs reimbursed from the Employee Reimbursement Account.

Employee’s *original Signature

Date

*This form requires an original signature and will not be processed if the signature is a copy.

Submit Claims to:

Department of Administration & Information

Human Resources / Employee Benefits

Attn: Cafeteria Plan Section

2001 Capitol Avenue

Emerson Building, Room 106

Cheyenne, WY 82002

(307) 777-6835

Revised 1/26/07 EGI-105

▼ Wyoming Medical Reimbursement File

Document Characteristics

Fact Name Details
Governing Law The Wyoming Medical Reimbursement form is governed by the Internal Revenue Code and Wyoming state regulations regarding flexible spending accounts.
Eligible Expenses Eligible expenses include qualified medical and dental expenses for employees, spouses, and dependents that are not covered by other sources.
Dependent Care Eligibility Expenses for dependents under age 13, disabled children, spouses, or parents may qualify, provided the employee is working during care.
Reimbursement Frequency Reimbursement requests can be submitted anytime, with payments issued semi-monthly directly to the employee.
Tax Implications Reimbursements for ineligible expenses may be taxed as ordinary income, and IRS penalties could apply.
Signature Requirement An original signature is required on the form; copies will result in processing delays or rejection.
Please rate Fill Your Wyoming Medical Reimbursement Template Form
4.84
Exceptional
19 Votes

Browse Common Forms

Wyoming Real Estate Commission - Includes contingencies for loan approval and property appraisals, ensuring the buyer is not penalized for financing issues beyond their control.

Address in Wyoming - Designated fields for agency use underline the form's role in internal processing and vendor management within state departments.

For anyone setting up a Limited Liability Company, understanding the key elements of an effective Operating Agreement is vital for legal compliance and operational success. This document provides clarity on management duties and can significantly influence the decision-making process within the LLC. For more insights, consider reviewing our guide on how an Operating Agreement can benefit your LLC.

Wyoming Ifta - Incorporates a clear layout for totaling page summaries, ensuring that all necessary calculations are straightforward and accurately compiled.