Special Food Expense Form
Employee Benefits Corporation
Secure upload at:
Fax to: Mail to: Phone support:
E-mail support:
www.ebcflex.com
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126, 608 831 8445, M - F 8:00 - 5:00 Central
[email protected]
Account Holder Information
Last 4 Digits of Social Security or Identification Number
(Required)
Last Name
First Name
E-mail Address (we do not share your e-mail address)
Employer
Special Food Expenses
$
Specialty Food
(Example) Gluten-Free Spaghetti 8 ounces
$
Specialty Food Cost
$.30 per ounce
Regular Food Cost
$.09 per ounce
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*See FAQ on the next page for calculation instructions.
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Medical Expense
$1.68*
Total
Signature - This certifies that my statements on this Special Food Expenses Form are complete and true.
X
Signature
Date (mm-dd-yyyy)
Print Name
© 2011 Employee Benefits Corporation
8065-0 12/11
Special Food Expense Form
Employee Benefits Corporation
Secure upload at:
Fax to: Mail to: Phone support:
E-mail support:
www.ebcflex.com
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126, 608 831 8445, M - F 8:00 - 5:00 Central
[email protected]
Claim Submission
Follow these steps to submit your special foods as a medical expense:
1. Your medical care provider will need to complete a Letter of Medical Necessity.
To assist you, this form is available on our website at www.ebcflex.com.
You will need to submit a new Letter of Medical Necessity every year.
2. Complete the Special Foods Expense section above comparing your specialty food
to regular foods.
3. Sign that the expenses are true.
4. P rovide the receipt from the grocery store with the date the food items listed above
were purchased.
5. Transfer the TOTAL amount to your Claim Form.
6. Enter the date on the receipt as the Date of Service on the Claim Form.
7. S ubmit your completed Letter of Medical Necessity, Claim Form, Special Food
Expenses Form and grocery store receipt.
Frequently Asked Questions
What is a special food?
Generally foods are considered a personal living expense and cannot be reimbursed
as a medical expense. A specialty food is altered in its preparation to treat a
medical condition.
What is the medical expense associated with special foods?
The excess cost of specially prepared foods designed to treat a medical condition
over the ordinary foods which would have been consumed is a medical expense.
What are some examples of special foods?
Gluten-free foods for persons with celiac disease would be one example of special
foods. These gluten-free foods may include such things as pasta, bread and other
baked goods. Infants who cannot use commercial baby formula may need to have
prescription formulas due to allergies or lactose or soy intolerance.
Are diet foods a special food?
No. These foods are prepared with lower calories and fat, but have not been altered
from ordinary foods.
© 2011 Employee Benefits Corporation
8065-0 12/11
How do I calculate the cost of specialty foods and regular foods?
You will need to compare similar items while grocery shopping. Per IRS guidelines, it is
up to the participant to compare and submit prices. As a suggestion, try to find items that
are similar in type, size, weight, packaging, etc.
For example, you purchase DeBoles Gluten Free Rice Spaghetti pasta for $2.39
(8 ounces) and then compare it to spaghetti pasta found in the pasta aisle of your local
grocery store. You should look for spaghetti that is similar in type and amount.
Barilla Spaghetti is $1.39 (16 ounces).
There are two options to determine price. You may wish to buy two boxes of the gluten
free pasta to compare to the 16 ounces of regular pasta. Or, you may wish to be more
technical and determine the cost per ounce. Gluten-free pasta is .30 cents per ounce
($2.39/8) and regular pasta is .09 cents per ounce ($1.39/16). The difference is .21 cents
per ounce. In this example, 8 ounces of specialty food would equal $1.68 in medical
expense (.21 cents x 8 ounces).