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2. Per government regulations, you can’t use FSA money and be reimbursed from another health plan.
6. Optical Plan
   Optical Plan Explanation of Benefits (PDF)

   Use the link above to review the County's optical plan.

10. Employee First Name*
11. Employee Last Name*
13. Agency*
    -- Select One --Kenton County Fiscal CourtPDS/Area PlanningKenton County AttorneyKenton County Clerk's OfficeKenton County Sheriff's OfficeTBNKY
14. Department*
    -- Select One --AdministrationAnimal ServicesBuildings & GroundsDetention CenterDispatchFiscal CourtHomeland Security Emergency ManagementParks & RecreationPolicePublic WorksTechnology ServicesTreasury
16. Employee Email
17. Employee Phone Number
21. Patient Information
23. Patient First Name*
24. Patient Last Name*
26. Patient Address*
27. Address Line 2
29. City*
30. State*
31. Zip Code*
35. Date
    Date
36. Service Provider
37. Amount
38. Reimbursement Amount
40. Date
    Date
41. Service Provider
42. Amount
43. Reimbursement Amount
45. Date
    Date
46. Service Provider
47. Amount
48. Reimbursement Amount
50. Date
    Date
51. Service Provider
52. Amount
53. Reimbursement Amount
55. Total Amount Requested, not to exceed $300.00*
57. As a stand-alone plan from the Medical Plan, employees may file reimbursement claims for dependents under the age of 22 or 25 if the dependent is a full-time student. Please upload proof of student status if over the age of 22.
59. File Upload
    This can be either a doctor's receipt, glasses receipt or similar document.
60. File Upload
    This can be either a doctor's receipt, glasses receipt or similar document.
61. File Upload
    This can be either a doctor's receipt, glasses receipt or similar document.
62. File Upload
    This can be either a doctor's receipt, glasses receipt or a similar document.
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field