Post on 28-Mar-2015
The most current form is always available on the Trust website
Versions older then 2010 are no longer acceptable.
The date of the form will be found at the bottom right hand corner
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
Retiree Name Current Contact Information
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
Please make sure we have your current e-mail address. It's an important method of communication with you.
Check this box if you have a new address. Make sure we can notice it.
Date of Service
Name Of Patient
Total Amount of Expense
If applicable, amount
insurance covered, any
discounts applied
Patients responsibility
Retiree Signature and
Date
Filling Out Your Reimbursement Forms (continued)
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
Date the service was actually provided. Statement date or payment date only OK if service date not available.
Joe Retiree
Prescriptionso Must Include:
Drug name Cost Date Patients name
o Examples Pharmacy stubs or
print out Over the counter
drugs with Dr. prescription only
o Will not accept: Cash register receipt
or payment confirmation alone.
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
Cash Register Receipts Alone is Not Sufficient
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
Balance forward does not describe service provided. Proof must indicate what product or service was purchased
The following expenses are currently eligible as of 2011:o Lasik eye surgeryo Dental implantso Viagrao Cialis o Or anything that
meets with the current IRS guidelines
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
It still might be eligible for reimbursement
Premiums are eligible for reimbursement but they are subject to aged base annual reimbursement limit. Following are the reimbursement limits for 2011.
Attained age before the close of Max reimbursement for year of the taxable year
o 40 or less $340
o More than 40 but not more than 50 $640
o More than 50 but not more than 60 $1,270
o More than 60 but not more than 70 $3,390
o More than 70 $4,240PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
o Please make sure not to submit anything to the Trust until it has been fully processed by your insurance.
o You may submit reimbursement claims no later then 365 days after the end of the calendar year in which the expense is incurred.
o Remember you can only get reimbursed for an expense once. Do not submit the same expense more then once.
PO Box 196650 Anchorage, AK 99519-9980 Fax: (907) 249-7622 Email: bretzld@muni.org
P.O. Box 196650 Anchorage, AK 99519-9980
Office: (907) 267-5094 Fax: (907) 249-7622
Email: bretzld@muni.org