Fillable Health Care Fsa Claim Form (Page 4 of 4) in pdf

Health Care FSA Claim Form

This document and any attachments are intended solely for the use of the sender and ADP and may contain information that is privileged and

confidential. If you are not the intended recipient or its authorized representative, you are hereby notified that dissemination of this information is

strictly prohibited. If you received this information in error, notify the sender immediately and destroy this document and all supporting attachments.

Tips to Remember when submitting Health Care FSA expenses.

1. Include your 10-digit FlexID. Locate your FlexID at

or by calling the Participant Solution Center at 1-800-654-6695.

2. Sign, Date and Fax your Claim Form without a cover page, followed by a copy of all supporting documentation including itemized receipts, bill or

statements, and/or Explanation of Benefits (EOB) showing date, provider, amount and type of service. Note: Many credit card receipts do not

show type of service and are therefore insufficient. Claims without sufficient documentation or signatures are ineligible for reimbursement.

3. Do not include a cover page or the instructions pages with your claim submission.

Employee Information

(PLEASE PRINT)

CyberSource - 26951

Name

Employer Name

(Please print name in ALL CAPITAL letters)

Address

City

State

Zip

Daytime Phone

FlexID

Instructions: Please

use blue or black ink

and print like this

Expense Information

Start Date of Service

NOTE: Please report only one expense per block. Combining multiple

Amount

expenses in one block may result in a delayed reimbursement.

MONTH

DAY

YEAR

DOLLARS

CENTS

NAME OF PROVIDER

TYPE OF SERVICE

OVER THE COUNTER

DENTAL

HEALTH

VISION

PRESCRIPTION

DEPENDENT NAME

DEPENDENT D.O.B.

RELATIONSHIP

TO EMPLOYEE

NAME OF PROVIDER

TYPE OF SERVICE

OVER THE COUNTER

DENTAL

HEALTH

VISION

PRESCRIPTION

DEPENDENT NAME

DEPENDENT D.O.B.

RELATIONSHIP

TO EMPLOYEE

NAME OF PROVIDER

TYPE OF SERVICE

OVER THE COUNTER

DENTAL

HEALTH

VISION

PRESCRIPTION

DEPENDENT NAME

DEPENDENT D.O.B.

RELATIONSHIP

TO EMPLOYEE

NAME OF PROVIDER

TYPE OF SERVICE

OVER THE COUNTER

DENTAL

HEALTH

VISION

PRESCRIPTION

DEPENDENT NAME

DEPENDENT D.O.B.

RELATIONSHIP

TO EMPLOYEE

To Expedite Processing Please Fax Your Claim To

Total

1- (866) 392-4090 (toll-free)

Expenses

Or Mail to: ADP Claims Processing, P.O. Box 1853, Alpharetta, GA 30023-1853

Certification

I certify that the expenses listed above qualify for reimbursement under the applicable IRS regulations and guidance and have been incurred by me or by

my eligible dependents. These expenses have not been reimbursed and I will not seek reimbursement under any other source. I understand that where

an expense is determined to be ineligible, I am responsible for reimbursing the plan for any such expense. Additionally, these expenses are not being

claimed as tax deductions under the IRS code. Bills, statements, receipts or other proof of the expenses are attached.

SIGNATURE

DATE

v20090101