Open Wyoming Medical Reimbursement Editor Here

Printable Wyoming Medical Reimbursement Form

The Wyoming Medical Reimbursement form is a document used by employees to request reimbursement for eligible medical and dependent care expenses under the state's Flexible Spending Plan. This form requires detailed information about the services provided, the amounts incurred, and the relationship of the dependents involved. To begin the reimbursement process, please fill out the form by clicking the button below.

Open Wyoming Medical Reimbursement Editor Here

Table of Contents

Form Properties

Fact Name	Fact Description
Governing Law	The Wyoming Medical Reimbursement form operates under the guidelines set by the Wyoming Flexible Spending Plan and the Internal Revenue Code.
Eligibility	Eligible expenses include qualified medical and dental expenses for the employee, spouse, and dependents not covered by other sources.
Dependent Care Definition	Eligible dependents for reimbursement include children under 13, disabled children, disabled spouses, or dependent disabled parents.
Reimbursement Frequency	Reimbursements are issued semi-monthly, directly to the employee, based on claims submitted.
Required Documentation	An explanation of benefits (EOB) must be attached for any expenses that may be covered by insurance.
Signature Requirement	The form requires an original signature from the employee; copies will not be accepted.
Tax Implications	Expenses reimbursed may be taxed as ordinary income if deemed ineligible by the IRS, and penalties may apply.
Contact Information	For claims status and general information, employees can contact the Employees’ Group Insurance Office at 777-6835 or 1-800-891-9241.

Documents used along the form

The Wyoming Medical Reimbursement form is a key document in managing medical expenses through a flexible spending plan. However, several other forms and documents are often required to support the reimbursement process. Below is a list of commonly used forms that accompany the Wyoming Medical Reimbursement form.

Explanation of Benefits (EOB): This document outlines the services covered by your insurance, detailing what has been paid and what remains your responsibility. It is essential for verifying the eligibility of expenses.
Itemized Invoices: These are detailed bills from service providers that specify the services rendered, costs, and payment terms. They must be attached to substantiate your reimbursement claims.
California Release of Liability Form: This document is essential for waiving the right to sue for potential claims of harm or damage during activities with inherent risks, allowing participants to acknowledge these risks before proceeding. For more information, visit smarttemplates.net.
Dependent Care Provider Agreement: This form is used to outline the terms of care provided for dependents. It may include details about the provider's qualifications and the care arrangement.
Tax Credit Claim Form: If you wish to claim a tax credit for dependent care costs, this form is necessary. It ensures you comply with IRS regulations regarding tax benefits for dependent care.
Flexible Spending Account (FSA) Enrollment Form: This document is used to enroll in the flexible spending plan. It details your contributions and the benefits you can access.
Provider's Signature Form: This form may be required to confirm that a dependent care provider has rendered services. It serves as proof of care and may be necessary for reimbursement.
Claim Submission Form: This is a general form used to submit claims for various reimbursements, including medical and dependent care expenses. It typically requires basic information about the claimant and the claim.
IRS Form 2441: This form is used to claim the Child and Dependent Care Expenses Credit on your tax return. It helps report eligible expenses and calculate your tax credit.

In summary, having the right documentation is crucial for a smooth reimbursement process. Each of these forms plays a vital role in ensuring that your claims are processed efficiently and accurately. Be sure to gather all necessary documents before submitting your reimbursement requests to avoid delays.

Misconceptions

Misconceptions about the Wyoming Medical Reimbursement form can lead to confusion and errors in the reimbursement process. Here are six common misconceptions explained:

All medical expenses are eligible for reimbursement. Many people believe that any medical expense can be reimbursed. However, only qualified medical and dental expenses that are not covered by insurance are eligible.
Dependent care expenses can be claimed regardless of employment status. Some individuals think they can claim dependent care expenses even if they are not working. To qualify, the employee must be gainfully employed while the dependents receive care.
Reimbursement claims can be submitted at any time without restrictions. While requests for reimbursement can be submitted anytime, there is a specific processing schedule for payments. Understanding this schedule is important for timely reimbursements.
Reimbursement amounts are automatically tax-free. It is a common belief that all reimbursements are tax-free. However, if the IRS determines that an expense is ineligible, it may be taxed as ordinary income, and penalties could apply.
Receipt signatures are always required for reimbursement. Some may think that a signature from the dependent care provider is mandatory for all claims. In fact, a receipt can be attached in lieu of a signature in certain cases.
Expenses reimbursed cannot affect tax credits. Many people do not realize that if they receive reimbursement for dependent care costs, they cannot also claim a tax credit for those same expenses on their personal tax return.

Document Example

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: Usage Guidelines

Once you have gathered the necessary information and documentation, you can start filling out the Wyoming Medical Reimbursement form. Follow these steps to ensure your claim is completed accurately.

Begin by entering your Agency Name and Agency # at the top of the form.
Fill in your Social Security Number, followed by your Last Name and First Name.
Provide your Home Address, including City, State, and Zip Code.
Enter your Daytime Telephone Number.
For the medical reimbursement section, complete the following fields:

Date of Patient Requested Service
Provider Name
Service Name
Relationship to the patient
Age of the patient
Amount for each service provided

Calculate and enter the Total Medical Reimbursement Requested.
For the dependent day care reimbursement section, complete the following fields:

Date of Dependent Requested Care
Name & ID# of Provider
Care Name
Relationship/Age of the dependent
Amount for each service provided

Calculate and enter the Total Dependent Care Reimbursement Requested.
If applicable, have the Dependent Care Provider Signature on the form, or attach a receipt.
Sign the back page of the form to certify the information provided.
Attach any necessary documentation, including an Explanation of Benefits (EOB) for covered items.
Submit the completed form and attachments to the specified address:

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

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