Fsa Claim Form
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1FSA CLAIM FORM
If you have any questions call (866) 916-3475
Claim Submission Methods
F
:
(877) 213-8917
ax
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17 Court Street Suite 500 Buffalo, NY 14202
Today’s date: ______/______/______
______# of pages
Plan Year beginning for: 20______
New claim
Re-submission of claim
Response to claim denial
FSA ID Number or Social Security Number:
Employee Name:
Address:
Home Phone: (
)
E-mail Address:
Work Phone: (
)
Medical Expense Reimbursement Account
Total Amount Requested:__________
• Enclose insurance company statement or itemized bill from provider showing date of service, services rendered, provider
of service, amount paid and, if applicable, amount covered by insurance
• Prescription claims MUST include the Rx number pharmacy receipt, not the cash register receipt
Dependent Care Reimbursement Account
Total Amount Requested:__________
Note: you MUST include provider Tax ID Number in the service provider column below. If you do not remit a copy of your bill/con-
tract, your provider must sign on the line below in lieu of submitting a receipt.
Provider Signature: ___________________________________
Date______/______/______
Type of Service (Rx,
Service Provider/
Employee, Spouse or
Date of Service
Amount Requested
co-pay, dental expense,
Rx Number (Must be
Dependent
etc).
provided)
1.
2.
3.
4.
5.
CLAIM SUBMISSION REQUIREMENTS
• Please number each receipt according to the order of appearance on this form
• IRS guidelines do NOT consider cancelled checks as valid documentation
• Previous balances are NOT acceptable
• All reimbursements will be made payable to the employee
I certify that the above listed expenses have been incurred by me, my spouse or my dependent(s) and that they have not been reimbursed
under any other health plan. I will not seek reimbursement for these expenses under any other health plan.
Employee’s Signature:_______________________________
Date:______/______/______
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