WebREIMBURSEMENT CLAIM FORM. Use this form for dependent child . or adult daycare expenses. 4. if this includes documentation for previously denied claim. 4. if new email address . 4 . ... • Household limit for dependent care reimbursement cannot exceed $5000 per year, including annual election, any child care subsidies that received, and/ Web4. Please submit claim reimbursement for each patient on a separate claim form. 5. Please note that the member’s (or employee’s or authorized person’s) signature is required on this form. 6. Mail completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham, NY 12110. 7.
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