Read Microsoft Word - MILDLY ILL CHILD CARE Cover Letter FInal 1 19 07.doc text version

BENEFITS DEPARTMENT

Mail Stop S-HR3 P.O. Box 34067 Seattle, WA 98124-1067

RE: Mildly Ill Child Care Program Dear Partner, Thank you for inquiring about the Mildly Ill Child Care Program. Having an ill child is always a concern. Not only does your child not feel well, but most child care providers and schools will not accept children with mild symptoms. Starbucks offers resources to assist you in finding and paying for back-up child care. Mildly Ill Child Care Referrals It is not always possible to stay home and care for your child. Aetna EAP (Employee Assistance Plan) can assist you in finding back-up care whether it is at a medically supervised facility within a hospital or in-home care. Call Aetna at 1-800-682-0364 for referral information. As with all child care, it is best to plan ahead. Calling facilities to inquire about availability in advance maximizes your child care choices. Pre-registering your child with a provider saves you time. When your child gets sick, you can simply call the child care provider to arrange care. Financial Assistance In addition to assistance finding back-up care for your child through Aetna EAP, Starbucks will reimburse you 50% of the daily fee, up to a maximum of $30.00 per day, up to five days per year. You will need to pay for services up front and request reimbursement from Starbucks afterward. How to File a Claim 1. Complete the Mildly Ill Child Care claim Form. 2. Attach your child care provider receipt. 3. Fax or mail the claim form and receipt to: 206-318-7812 Fax

Starbucks Benefits Department Mail Stop S-HR3 PO Box 34067 Seattle, WA 98124-1067

If you have questions about the Mildly Ill Child Care Program, please contact Starbucks Health Privacy Office at 1-888-796-5282 ext 84708. Sincerely, Starbucks Benefits Department

Revised 1/19/07

MILDLY ILL CHILD CARE CLAIM FORM

Directions: Complete all three sections of this form and sign/date the bottom. Section 1: Partner Information Name ___________________________________ Partner # _____________________ E-Mail __________________________________ Telephone # __________________ Home address ________________________________________________________________ Section 2: Claim Information Date of Claim ______________ Total Claim Amount* $________________

*You must provide either a receipt to verify expense or the signature of the provider in Section 3. Section 3: Provider Information Provider's Name ______________________________________________________________ Provider's Address ____________________________________________________________ Provider's Social Security # - Tax ID # _________________________________________

If the PROVIDER OF CARE is signing to verify that services have been rendered on your behalf as an alternative to providing a receipt, the provider is required to sign here:

Signature of Provider of Care ____________________________________________________

Important Note: Generally, any reimbursements under this plan when combined with claims reimbursed under the Dependent Care Reimbursement Account that exceed $5,000.00 for the plan year are considered taxable income and will be included in your W-2.

Partner's Signature _____________________________________ Date __________________

If you have questions about the Mildly Ill Child Care Program, please contact Starbucks Health Privacy Office at 1-888-796-5282 ext 84708. Fax or Mail claim to:

206-318-7812 (Fax)

Starbucks Benefits Department Mail Stop S-HR3 PO Box 34067 Seattle, WA 98124-1067

Revised 1/19/07

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Microsoft Word - MILDLY ILL CHILD CARE Cover Letter FInal 1 19 07.doc