Form Gc-1578 - Aenta - Reimbursement Request
Download a blank fillable Form Gc-1578 - Aenta - Reimbursement Request in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gc-1578 - Aenta - Reimbursement Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reimbursement Request
Date
U
FAX - # Pages
Please follow the steps below to thoroughly and accurately complete this form.
STEP 1: Company Name
Day Phone
U
U
U
STEP 2: Employee Name
SSN
U
U
U
STEP 3: FLEXIBLE SPENDING ACCOUNT CLAIMS
Date of Service
(MM/DD/YYYY)
Name of Provider
Description of Service
Claim Amount
$
$
$
$
$
$
$
STEP 4: CHILD/DEPENDENT CARE CLAIMS
Date of Service
(MM/DD/YYYY)
Name of Provider
Provider Tax ID/SS#
Description of Service
Claim Amount
$
$
$
$
Total
$
Payout Schedule – Claim Reimbursement Checks are distributed twice a month.
th
th
th
th
If claims are received by 5 p.m. on the 5
/20
of the month, reimbursement checks/reports will be sent to the employer by the 15
/30
.
STEP 5: 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.
I further certify that the above dependent care expenses are for the care of a Qualifying Person and do not include separate charges for
food, clothing, education, entertainment, activities, late fees, or overnight care. 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 ►Signature of Employee
Date
Submit a Reimbursement Request in four easy steps….
1.
Provide acceptable proof of paid expenses. We request that you send COPIES of your proof of expenses since they will not be
returned to you. For tax purposes, you should retain the original proof of expense.
Flexible Spending Account – A copy of the explanation of benefits sent to you by your carrier stating the portion of the claim paid OR
a copy of the bill from the provider stating the services and date performed and method of payment used.
Child/Dependent Care – A copy of receipt from care facility, referencing their tax I.D. number (or SS#) and the dates of coverage.
2.
Write the total amount for reimbursement which can be found in Step 4.
3.
Attach all copies pertaining to your claim to this form and fax to 1-847-332-0335.
4.
Send request for reimbursement via mail or fax to: Aetna FSA
10275 W. Higgins Road, Suite 500
Rosemont, IL 60018
Phone: 1-866-472-0897
Fax: 1-847-332-0335
GC-1578 (10-10)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business