Bcbs Form - Request For Reimbursement Preferred Health Fsa/hra
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1
2REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA
Attach a copy of the itemized bill and an Explanation of Benefits (EOB) (if applicable) along with proof of
payment. All documentation must include the patient name, description of service provided, date provided, and
the charge. Be sure to sign and date this form before sending it with all attachments to the address shown.
An Independent Licensee of the Blue Cross and Blue Shield Association
I certify that the attached expenses are eligible for reimbursement from my designated Health FSA/HRA and that they qualify as deductions
Blue Cross and Blue Shield of Alabama
as outlined by the U. S. Internal Revenue Code or by my employer. I request reimbursement up to the limit allowed in my account. I further
Preferred Blue Accounts
certify that these expenses have not been reimbursed and are not reimbursable under any other benefit plan. A dependent must be
P.O. Box 11586
considered an eligible dependent under the applicable provisions of section 105 and 106 of the U.S. Internal Revenue Code.
Birmingham, Alabama 35202-1586
1-800-213-7930
Signature of Employee
Date
Toll Free Fax 1-877-889-3610
Visit our web site
/
/
for detailed account information
Important: This form is not used to reimburse you for your Blue Cross and Blue Shield of Alabama health benefits. It may only be used to request a payment from a tax-deferred, employee-funded spending account
established by your employer under Section 125 of the U.S. Internal Revenue Code or from your HRA established by your employer. Payments from such an account may only be made for qualified expenses on behalf of
qualified dependents when such expenses have not been reimbursed and are not reimbursable by any other benefit plan.
SECTION 1:
EMPLOYEE INFORMATION
FIRST NAME
MI
LAST NAME
DATE OF BIRTH
PREFERRED BLUE ACCOUNT NUMBER
NOTE: Your Preferred Blue Account number is your Blue Cross and
Blue Shield of Alabama contract number. If you do not have
your account number, please contact Customer Service at
–
/
/
1-800-213-7930.
COMPANY NAME
WORK PHONE (Please include area code)
HOME PHONE (Please include area code)
SECTION 2:
HEALTH FSA/HRA REIMBURSEMENT INFORMATION
In order to be properly reimbursed, complete this section for each eligible expense and attach all necessary itemized receipts. (PLEASE DO NOT HIGHLIGHT ITEMS ON YOUR RECEIPTS.)
PATIENT’S FIRST NAME
LAST NAME
TYPE SERVICE
MEDICAL
VISION
AMOUNT
DENTAL
RELATIONSHIP
SELF
SPOUSE
DEPENDENT
COVERED BY INSURANCE
YES
NO
ORTHODONTICS
DATE OF BIRTH
DATE OF SERVICE
RX/OTC
/
/
/
/
PREMIUM*
•
OTHER
TYPE CHARGE
COPAY
DEDUCTIBLE
COINSURANCE
OTHER
DOCUMENTATION ATTACHED
YES
NO
TYPE SERVICE
PATIENT’S FIRST NAME
LAST NAME
MEDICAL
VISION
AMOUNT
RELATIONSHIP
SELF
SPOUSE
DEPENDENT
COVERED BY INSURANCE
YES
NO
DENTAL
ORTHODONTICS
DATE OF BIRTH
DATE OF SERVICE
/
/
/
/
RX/OTC
OTHER
•
TYPE CHARGE
DOCUMENTATION ATTACHED
COPAY
DEDUCTIBLE
COINSURANCE
OTHER
YES
NO
TYPE SERVICE
PATIENT’S FIRST NAME
LAST NAME
MEDICAL
VISION
AMOUNT
RELATIONSHIP
SELF
SPOUSE
DEPENDENT
COVERED BY INSURANCE
YES
NO
DENTAL
ORTHODONTICS
DATE OF BIRTH
DATE OF SERVICE
RX/OTC
/
/
/
/
OTHER
•
TYPE CHARGE
COPAY
DEDUCTIBLE
COINSURANCE
OTHER
DOCUMENTATION ATTACHED
YES
NO
TYPE SERVICE
PATIENT’S FIRST NAME
LAST NAME
MEDICAL
VISION
AMOUNT
RELATIONSHIP
SELF
SPOUSE
DEPENDENT
COVERED BY INSURANCE
YES
NO
DENTAL
ORTHODONTICS
DATE OF BIRTH
DATE OF SERVICE
RX/OTC
/
/
/
/
OTHER
•
TYPE CHARGE
DOCUMENTATION ATTACHED
COPAY
DEDUCTIBLE
COINSURANCE
OTHER
YES
NO
*The premium reimbursement is available to select HRA plans only.
TOTAL
•
CL-472 (Rev. 11-2014)
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