Expense Reimbursement Voucher Template

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EXPENSE REIMBURSEMENT VOUCHER FOR
HEALTH FLEXIBLE SPENDING ARRANGEMENT (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.
110-173) requires American Fidelity to report certain HRA data to the Centers for
Expense Total:
$ 0.00
(must be completed)
Medicare & Medicaid Services.
EXPENSE GUIDELINES: All documentation attached must have a detailed explanation of the date, type, and amount of each
service rendered. Reimbursements for a Health FSA cannot be made until the first deposit of each plan year has been
received from your employer. 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 balance. To the best of my knowledge my statements on this form are true and
complete. I certify that either I, my spouse, or my dependent (qualifying child or qualifying relative as defined in Code Section 152) or
qualifying adult child (as amended in Code Section 105 to be included as a dependent with respect to benefits provided after March 30,
2010) has received the services described above on the dates indicated and that the expenses qualify as valid medical care expenses under
Code Section 213 (d). I certify that these expenses have not been reimbursed under a major medical plan or any other health plan, such as
an individual policy or my spouse’s or dependent’s health plan, a Health Savings Account, or other reimbursement account.
I understand
that the expense 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 0612
KEEP A COPY OF ALL CLAIMS SUBMITTED FOR YOUR RECORDS

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