Medical Reimbursement Program Claim Form

Skip to the file available for download.

Download the form below to apply for medical reimbursements.

This program assists with medical expenses that are not covered under your health insurance policy. As well, you may claim reimbursement of health insurance premiums you paid for a policy that includes you. Your Plan C quarterly statement lets you now how much of your CAPP account balance may be used for medical reimbursement.

In order to qualify for reimbursement under Plan C –MRP, a health care expense must meet all of the following requirements:

  1. It is incurred after the effective date of your coverage.
  2. It is on the lists of qualifying expenses. See pages
    25-31 of the Plan C SPD.
  3. It has not been and will not be reimbursed by Plan C1, C2, C3 or any other coverage.
  4. It is submitted with appropriate documentation, including:

    - A detailed statement or bill that includes the name, address, phone number and tax ID number of the provider; the patients name, address, birth date and relationship to the member; and an itemization and description of the service(s) provided.

    - A copy of an Explanation of Benefits (EOB) or other statement from an insurance company or other provider showing denial of reimbursement or proof that the expense is not reimbursable. It must be rendered by a licensed provider, in accordance with applicable law. In addition, the claim must be received by ASO/SIDS by the March 31 following the calendar year in which the health expense incurred.

  5. Completed forms, together with any other pertinent attachments, should be sent to:

    SIDS, Dept 51
    PO Box 9005
    Lynbrook, NY 11563-9005


     

    File for DownloadSize
    Reimbursement Claim Form 2011.pdf100.67 KB

    Download Acrobat Reader