Flexible Benefits
Health Care
Reimbursement Claim Form
Instructions for Online Claim Filing
Claims may be filed online at www.mgmflex.com. Log into your account and enter your claim information under
the “File Claims” section.
Instructions for Manual Claim Filing
Please print or type all information for manual claims request.
Your Assigned Employee Number can be found on your participant website at
www.mgmflex.com
Attach copies of receipts, including date of service, patient name, provider information and amount of eligible
expenses.
Do not submit original copies of receipts; they will not be returned.
Fax claims to (800) 973-3702.
Employee Information
Employer Name
Date
Last Name
First Name
MI
SSN
Or
Assigned Employee Number
Mailing Address
City
State
Zip
Email Address
((P
lease print clearly - You will receive important emails regarding claims and
payments on your Flexible Plan Accounts
)
Contact Phone Number
I certify that the expenses listed below were incurred by me or my eligible dependents during the applicable plan year and qualify for
reimbursement. The reimbursements requested have not been reimbursed or reimbursable from any other source. I understand that I
may be requested to provide additional explanation for the requested reimbursements, and it is my responsibility to maintain copies of
all documentation for my records. I fully understand that I am responsible for the accuracy of all information relating to the claim
provided.
Signature of Participant
Date Signed
Medical FSA Claim Information
Please keep your original receipts for your records
. Attach copies of bills, receipts or other evidence of eligible out-of-pocket expenses
for reimbursement. For expenses to be reimbursed from a Group Insurance Carrier, please attach an Explanation of Benefits (EOB).
Canceled checks and credit card receipts are not considered sufficient documentation.
Date
Service
Incurred
Patient Name
Provider Name
Description of Service
(e.g., RX, co-pay, dental, office visits, etc.)
Amount
Requested
Total Requested
MGM Benefits Group
2121 N. Glenville Drive
Richardson, TX 75082
Phone: (800) 833-4028
Fax: (800) 973-3702
FlexSupport@MGMBenefits.com
