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This is to certify that I have incurred the expenses listed above for myself, my spouse or qualifying dependents, that the expenses detailed above are eligible for reimbursement in accordance with applicable governmental rules and regulations for the benefit plan(s) that I am enrolled in. I further understand that I am solely responsible for the validity of my claims. I have retained originals or copies of all documents submitted including documentation of reimbursement to me provided by other benefit plans. I understand and agree that since these expenses are to be reimbursed, they may not be claimed for any other purpose nor have they been previously submitted for reimbursement. I understand that should these expenses be reimbursed to me by other benefit coverage (i.e. duplicate payments), I shall return the monies paid to me by this plan, for recrediting to my account. I hereby request that the plan reimburse me for expenses identified above and contained within the attachment(s).

By clicking Submit, I understand and agree with the above statements.