Reimbursement: CAS Medical Claim Form
Did you have to use your debit or credit card to make a purchase for a qualified expense? You can receive a reimbursement from your account by logging on to your participant portal, mobile app, or by submitting a claim or distribution request form to our office for processing. Our email is email@example.com.
A medical claim must be for dates of service that were incurred within the plan year. To process a reimbursement, the IRS requires CAS to obtain the following:
- The patient’s name
- The provider’s name or clinic where the service was provided
- The type of service provided
- The amount owed or paid
How to submit a claim for dependent care expenses
Complete the CAS dependent claim form seen below and submit to our office for processing. Our email is firstname.lastname@example.org.
You can submit your dependent care claim for the entire plan year and receive your reimbursements from the account automatically as they are contributed from your payroll.
Contact our office to speak to our claims department for more information or assistance with completing the form.
All dependent care claims require the following:
- Dependent’s name
- Dependent’s age
- Provider or clinic of the service
- Provider’s tax ID number (or, if an individual, their social security number)
- The date the care service was provided.
- If you are providing a detailed billing statement, the dependent care provider’s signature is not required.
- However, if you are not providing documentation, the provider must sign the form to confirm the claimed charges.
Reimbursement: CAS Direct Deposit Form
If you’d like to get your reimbursement check earlier or if you prefer your reimbursements direct deposited to your checking account, you can fill out the CAS direct deposit form we will add the information to your account. Direct deposits process in 2-3 business days.
You may also add your information through the CAS Participant Portal.
Additional CAS Card Request Form
If you need an additional card for your spouse or dependent please fill out the additional CAS card request form. After completion of the form, please submit it to our office and you will receive your dependent’s card in 7-10 business days. Our email is email@example.com.
Sample Letter of Medical Necessity (LMN)
What is a Letter of Medical Necessity (LMN)?
It is a letter written by your doctor that verifies the services or items you are purchasing are the diagnosis, treatment or prevention of a disease or medical condition. It is to show this is not for general health.
What your LMN must outline?
What medical condition is being treated, a description of the treatment (frequency, dosage), and how the expense will be needed to treat the condition. The LMN works as a prescription and is only good for 1 year from the date written.
What does your LMN cover?
Beyond its direct medical use, most expenses are non-reimbursable if the individual would have purchased it anyway. Simply put, this product can’t be something you would purchase even if you didn’t have the condition. It needs to be directly related to this course of treatment and the specific use needs to be confirmed by a doctor or other medical practitioner.
Our email is firstname.lastname@example.org.
New HSA Contribution Form
If you want to contribute funds to your HSA outside of payroll, please complete the HSA contribution form and enclose your check or money order with the form to submit to our office. We can also process an electronic funds transfer (EFT) from your bank account to contribute the funds if you complete the CAS Direct Deposit form.
If you have any specific questions about how these forms can benefit you or what types of forms you would qualify for, contact us!
We would love to help you!
Call us between 8:00am and 5:00pm Monday through Friday: +1 (877) 941-5956