Healthcare Fsa Claim Form - Altogether Great - 2017 Page 2
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3REIMBURSEMENT FORM – HEALTHCARE EXPENSES
Use only CAPITAL LETTERS, completely fill in
ovals, and don’t use red ink.
XHXCXRX
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For additional expenses, please use next page.
SECTION 1: YOUR INFORMATION
SOCIAL SECURITY NUMBER OR EMPLOYEE ID (NO DASHES)
COMPANY NAME
EMPLOYEE LAST NAME
FOR ADP ONLY
EMPLOYEE HOME ZIP CODE
EMPLOYEE EMAIL
DAYTIME PHONE # (AREA CODE FIRST, NO DASHES)
SECTION 2: YOUR HEALTHCARE EXPENSES
EXPENSE 1
DATES OF SERVICE (MMDDYY)
REQUESTED AMOUNT (DOLLARS . CENTS)
COVERED BY INSURANCE?
COVERAGE CODE (SEE PAGE 1)
FROM
YES
NO
.
$
TO
PATIENT DATE OF BIRTH (MMDDYY )
EOB ATTACHED?
Please Select Code
YES
NO
EXPENSE 2
DATES OF SERVICE (MMDDYY)
REQUESTED AMOUNT (DOLLARS . CENTS)
COVERED BY INSURANCE?
COVERAGE CODE (SEE PAGE 1)
FROM
YES
NO
.
$
TO
PATIENT DATE OF BIRTH (MMDDYY )
EOB ATTACHED?
Please Select Code
YES
NO
EXPENSE 3
DATES OF SERVICE (MMDDYY)
REQUESTED AMOUNT (DOLLARS . CENTS)
COVERED BY INSURANCE?
COVERAGE CODE (SEE PAGE 1)
FROM
.
YES
NO
$
TO
PATIENT DATE OF BIRTH (MMDDYY )
EOB ATTACHED?
Please Select Code
YES
NO
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