Form Gc-11-4 - Limited Fsa Health Care Reimbursement
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1
2Limited Flexible Spending Account
Mail or fax completed form and documentation to:
Aetna Inc.
Health Care Reimbursement
0 B
PO Box 4000
(Limited & Post-Deductible)
Richmond, KY 40476-4000
Fax to: 1-888-238-3539 (1-888-AET-FLEX)
For the hearing impaired, call 1-877-703-5572 TDD/TTY
***
Y ou must sign and date this form to avoid claim payment delay.
***
U
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*** Refer to Instructions on reverse side. ***
1. Employee Information
Employee’s FSA Identification Number
Employee’s Last Name
First
MI
Daytime Telephone Number
W
(
)
-
Street Address
City
State
Zip Code
2. Employer Information
Employer Name
FSA Control Number
3. Expense Information
Date of Birth (MM/DD/YYYY
)
Patient’s First Name
Relationship to Employee
Self
Spouse
Dependent
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
Date of Birth (MM/DD/YYYY
)
Patient’s First Name
Relationship to Employee
Self
Spouse
Dependent
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
Date of Birth (MM/DD/YYYY
)
Patient’s First Name
Relationship to Employee
Self
Spouse
Dependent
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
Date of Birth (MM/DD/YYYY
)
Patient’s First Name
Relationship to Employee
Self
Spouse
Dependent
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
4. Orthodontia Expenses – Read Section 4 on the reverse side of this form before completing this section.
Date of Birth (MM/DD/YYYY
)
Patient’s First Name
Relationship to Employee
Self
Spouse
Dependent
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
5. Coordination of Benefits (COB)
6. Deductible Status
Are you or any family members for whom you are requesting reimbursement eligible to
Have you met your health plan deductible? After meeting the deductible, the
receive benefits under any medical, dental, prescription or vision plan other than your
limited FSA becomes a post-deductible FSA that reimburses for all qualified
primary coverage?
medical expenses incurred after meeting the deductible.
Yes – You must include copies of all EOBs.
No
Yes
No
7. Employee Certification
I certify that the expenses for which I am seeking reimbursement from the Flexible Spending Account have been incurred by me, or by
an individual who qualifies as my spouse or my dependent under IRS guidelines. I further certify that these expenses have not been
reimbursed, nor shall reimbursement be sought, from any other health plan coverage, including a Health Savings Account (HSA). I
also certify that I have not, and will not, claim a tax deduction or credit for these expenses on my federal income tax return, or on my
state or local tax returns in violation of state or local law. I agree to submit and retain sufficient documentation for any expense for
which I seek reimbursement.
Any person who knowingly and with intent to defraud files a statement of claim containing any materially false, incomplete or
misleading information is guilty of a crime.
Sign Here ► Employee Signature
Date
U
GC-11-4 (9-10)
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