Medical Travel Log/expense Reimbursement Voucher Template
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1AFES SECTION 125 FLEXIBLE BENEFIT PLAN
MEDICAL TRAVEL LOG/EXPENSE REIMBURSEMENT VOUCHER
For reimbursement of medical travel expenses only
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 #
Date of
Patient’s Name:
Location of Physician or
Type of
Number of
Total
Travel:
Treatment Facility
Treatment/Diagnosis:
Miles:
Reimbursement
Amount:
Expense Total:
$ 0.00
(must be completed)
I certify that the medical travel expense(s) listed above was incurred for transportation primarily for and essential to
medical care for myself or an eligible dependent. The medical care was provided by a physician in a licensed hospital or
medical facility, and no element of personal pleasure, recreation or vacation was involved in the travel. Travel to and from
a pharmacy does not qualify as medical care and is not eligible for reimbursement.
I authorize the above expenses to be reimbursed from my account balance. To the best of my knowledge my statements
on this form are true and complete. I certify that either I, my spouse, my tax dependent or my adult child who will be under
the age of 27 as of the end of the calendar year has received the services described above on the dates indicated and
that the expenses qualify as valid “medical care expenses” as defined by Internal Revenue Code Section 213(d). I certify
that these expenses have not been reimbursed under this or any other health plan and I will not seek reimbursement
under any other health plan. I understand that the expenses 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
FAX NUMBER: 1-800-543-3539
City, OK 73125-0510
PHONE NUMBER: 1-800-325-0654
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 VOUCHER MAY DELAY PROCESSING OR RESULT IN A DENIED CLAIM
KEEP A COPY OF ALL CLAIMS SUBMITTED FOR YOUR RECORDS
AFES rev 0213
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