Fillable Expense Reimbursement Voucher Template printable pdf download

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

Expense Reimbursement Voucher Template

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