MGM Benefits Group
2121 N. Glenville Drive
Richardson, TX 75082
Phone: (800) 833-4028
Fax: (800) 973-3702
FlexSupport@MGMBenefits.com
Flexible Benefits
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Dependent 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, dependent’s name, provider information and amount of reimbursement
request.
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
Change
of
Address
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 my dependent has received the services described on the service date indicated and that the expenses are valid
dependent care expenses. I further understand that funds will not be reimbursed to me in advance, and cannot exceed the amount of
funds available in my flex account at the time of my request. Funds that cannot be paid to me will be received as they become available
in my account. 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
Dependent Care Provider Information
Name of Dependent Day Care or Individual Provider
Tax ID Number or Social Security Number
Dependent Care FSA Claim Information
Please keep your original receipts for your records
. Attach copies of invoices for day care expenses.
Date Service
Incurred
Dependent Name
Date of Birth
Description of Service
(e.g., day care facility, day camp, etc.)
Amount
Requested
Total Requested
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