| MGM Benefits Group - Dependent Care Reimbursement Claim Form |
| 2010-11 |
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Handle:
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Document-4754
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Owner:
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McCabe, Perry (User-18, pmccabe:DocuShare)DS
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| Thursday, August 5, 2010 11:30:22 AM CDT |
| Thursday, August 5, 2010 11:30:22 AM CDT |
Modified By:
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Locked By:
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| - MGM Benefits Group 2121 N.
- Glenville Drive ? Richardson, TX 75082 ? Phone: (800) 833-4028 ? Fax: (800) 973-3702 ? FlexSupport@MGMBenefits.com Flexible Benefits 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.
- 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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| Allowed |
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Adobe Portable Document Format (.pdf) - application/pdf
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| DCAP Reimbursement Form.pdf |
| No |
| 4 |
| 67607 |
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| No |
Appears In:
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Section 125 and Insurance Forms, 403(b) & 457 Info., and Related Web Sites
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Preferred Version:
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MGM Benefits Group - Dependent Care Reimbursement Claim Form
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