FLEX / YES – Medical Expense Form

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Flex Yes - Medical Expense Request

Students have 100% insurance coverage from HCC for prescriptions and office visits for illnesses and injuries. Prescriptions must be paid for upfront and reimbursed once a claim has been processed. Please be sure that student insurance information is presented, and a claimant’s statement form has been submitted for all insured expenses. Student insurance information can be accessed at: https://www.envisageglobalinsurance.com/student-zone/greenheart/ This form applies to medical expenses not covered by insurance. Expenses not covered by HCC Medical Insurance, but covered by the FLEX and YES Grants include: • Student immunizations, required TB tests and physicals • Dental expenses not covered by insurance (pre-approval from Chicago office (flexyes@greenheart.org) required) • Eyeglasses (pre-approval from Chicago office (flexyes@greenheart.org) required) • Podiatric expenses (pre-approval from Chicago office (flexyes@greenheart.org) required) Please contact the office for approval of non-insured or prescription expenses that exceed $300.
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Instructions 1. Complete this form and attach invoices, bills, statements, or receipts keeping a copy for your own records 2. Please submit within 30 days of the time of the expense 3. Allow 10-15 business days for processing
Attached Receipts below
Max. file size: 80 MB.
Max. file size: 80 MB.
Max. file size: 80 MB.
Max. file size: 80 MB.
Max. file size: 80 MB.