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125 Cafeteria Plan Claim Form Complete, Sign and Send form, receipts and Jobs to: JEM Resource Partners Fax: 888-989-9247 900 S Capital of Texas Hwy, Suite 350 Austin, TX 78746 This and other important

All expenses not paid by you will be reported along with a copy of your current HMO medical plan and monthly statement. Your current HMO medical plan summary may be obtained from the Department of Public Safety at. This information cannot be sent to the Office of the State Auditor at State Auditor's Office, P.O. Box 633, Austin, TX 78751, or you will not be permitted to participate in the Texas Health Care Cost Containment System. You also cannot qualify as a JEM Participant if more than 730 days have passed from your last payment on your HMO medical plan. If you believe you are eligible for an exemption for this provision, please contact your State Agency for Health Care Services. Participant Information Name/Address (first name/last name): Employer (name of your employer or organization): Home Address (address): Work Phone #: Eligibility Exemptions (none) Exotic Animal Hospital, or Other Group Dental Program (GDP CP) JEM Provider Referral Jem Referral Program Medical Indemnity Plan (MIP) Claim Form Jem Resource Partners is the State Health Information Organization (HO) for the State Health Access Data Exchange, a new statewide health information exchange for Texans. We provide referrals to health care professionals who are eligible individuals or agencies that may be willing to offer you services through an MIP program. We are not the State, the State agencies or the agencies' staff. JEM does not directly process claims through the exchange but will refer you to the agency if it is able to do so. All information you supply will be kept confidential unless we are given a judicial subpoena or a court order by a party to any proceeding involving medical services provided under an MIP. If you are involved in a proceeding with health insurance company, you may wish to contact your health insurer. For more information, visit the Texas Department of Insurance. Health Care Provider Referral We are the sole provider referred to by applicants for health care services covered under an MIP. In order to be eligible to refer you to a health care provider, you must also be enrolled in the State General Enrollment System (SEES).

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