Expense Reimbursement Voucher For Health Fsa Or Hra
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1EXPENSE REIMBURSEMENT VOUCHER FOR
HEALTH FLEXIBLE SPENDING ACCOUNT (HEALTH FSA) OR
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
Name of Employee (Last, First, MI)
Social Security #
Mailing Address
E-mail address
Check here if this is a new address; if so, do you have other AF products?
Name of Employer
Daytime Phone #
For an HRA expense, if this person
Date of Expense
Name of Person for Whom the
Amount of Medical Expense
is or has ever been enrolled in
Expense Was Incurred
Medicare, you must provide this
persons Medicare Claim Number
(HICN)*
*Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (P.L.
$ 0.00
Expense Total:
110-173) requires American Fidelity to report certain HRA data to the Centers for Medicare
(must be completed)
& Medicaid Services.
EXPENSE GUIDELINES: All documentation attached must have a detailed explanation of the date, type, and amount of each
service rendered. Some Employer’s HRA Plans require an EXPLANATION OF BENEFITS (EOB) to be submitted with each
reimbursement request. Check with your Employer for details on your plan.
Acceptable Documentation to accompany the reimbursement voucher:
Unacceptable Documentation includes:
√
Professional bill or receipt that includes:
√ Cancelled checks or credit card receipts
• Provider of service
• Type of service rendered
√ Bill or receipt that only shows a balance forward/
• Charges for the service
• Original date of service
previous balance or payment due
NOTE: the date of service, not the date of payment
must fall within the dates of the plan year for which you are enrolled
√
Insurance Company Explanation of Benefits
√
Pharmacy Statement that includes Rx number and name of prescription
√
Over-the-counter drugs and medicine - medical practitioner’s prescription and receipt required.
I authorize the above expenses to be reimbursed from my account balance. To the best of my knowledge my statements on this form are true
and complete. I certify that either I, my spouse, my tax dependent or my adult child who will be under the age of 27 as of the end of the
calendar year has received the services described above on the dates indicated and that the expenses qualify as valid “medical care expenses”
as defined by Internal Revenue Code Section 213(d). I certify that these expenses have not been reimbursed under this or any other health
plan and I will not seek reimbursement under any other health plan. I understand that the expenses for which I am reimbursed may not be used
to claim any federal income tax deduction or credit. I further understand that I may be asked to provide further documentation or further detail
relating to an expense.
Signature of Employee
Date Signed
Mailing Address: American Fidelity Assurance Company, AFES Flex Account Administration, PO Box 25510, Oklahoma
City, OK 73125-0510
PHONE NUMBER: 1-800-325-0654
FAX NUMBER: 1-800-543-3539
American Fidelity will not be responsible for faxes not received. Health FSA average processing time is 5 to 7 working days
from receipt of a completed voucher; HRA average processing time may vary based on plan design. Additional Forms and
Account Information are available on our website at:
– under Claim & Flex Forms.
INCOMPLETE VOUCHERS MAY DELAY PROCESSING OR RESULT IN A DENIED CLAIM
AFES rev 0213
KEEP A COPY OF ALL CLAIMS SUBMITTED FOR YOUR RECORDS
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