Health Care Flexible Spending Account (Hcfsa) Program Claim Form

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Health Care Flexible Spending Account (HCFSA) Program
2)
EMPLOYEE (PARTICIPANT) INFORMATION (PLEASE TYPE OR PRINT CLEARLY)
.
last name
first name
mi
social security number
-
.
.
home address
number and street
check here if this is a new address
apt
no
city
state
zip code
(
)
(
)
home or cell
daytime
phone number
work phone number
agency name
not division
(
)
-
(
)
-
3)
HCFSA REIMBURSEMENT REQUESTS
Please read “Instructions and Important Information” on the reverse side before completing this form and refer to your enrollment information for
HCFSA rules and regulations. If the service was provided for more than one day, show the beginning date and the ending date of the service. Each
claim must be separated by patient, date/type of service and dollar amount.
.
patient last name
patient first name
mi
1
(
)
(
/
/
)
date
s
of service
mm
dd
yy
types of service
reimbursement amount requested
______/______/______
______/______/______
Medical
RX
OTC
Dental
Vision
$
from
to
(
)
claim period
check only one
2017 Plan Year (services incurred 1/1/17 - 12/31/17)
2016 Plan Year (services incurred 1/1/16 - 12/31/16)
2016 Grace Period (services incurred 1/1/17 - 3/15/17 using 2016 balance)
’
provider
s name
’
-
.
.
provider
s address
number and street
apt
no
city
state
zip code
.
patient last name
patient first name
mi
2
(
)
(
/
/
)
date
s
of service
mm
dd
yy
types of service
reimbursement amount requested
$
______/______/______
______/______/______
Medical
RX
OTC
Dental
Vision
from
to
(
)
claim period
check only one
2017 Plan Year (services incurred 1/1/17 - 12/31/17)
2016 Plan Year (services incurred 1/1/16 - 12/31/16)
2016 Grace Period (services incurred 1/1/17 - 3/15/17 using 2016 balance)
’
provider
s name
’
-
.
.
provider
s address
number and street
apt
no
city
state
zip code
.
patient last name
patient first name
mi
3
(
)
(
/
/
)
date
s
of service
mm
dd
yy
types of service
reimbursement amount requested
______/______/______
______/______/______
Medical
RX
OTC
Dental
Vision
$
from
to
(
)
claim period
check only one
2017 Plan Year (services incurred 1/1/17 - 12/31/17)
2016 Plan Year (services incurred 1/1/16 - 12/31/16)
2016 Grace Period (services incurred 1/1/17 - 3/15/17 using 2016 balance)
’
provider
s name
’
-
.
.
provider
s address
number and street
apt
no
city
state
zip code
$___________________
TOTAL REIMBURSEMENT AMOUNT REQUESTED (1+2+3)
0.00
4)
EMPLOYEE (PARTICIPANT SIGNATURE)
The above is a true and accurate statement of unreimbursed health care expenses incurred by me and/or my eligible dependent(s) on the date(s) indicated. I
certify that I and/or my eligible dependent(s) have incurred these expenses and have not been previously reimbursed and are not eligible for reimbursement
through any other plan. I understand that expenses reimbursed herein cannot be deducted from my or anyone else’s individual Federal Income Tax return. All
claims submitted by me comply with the rules and definitions as set forth on the reverse side of this form. I understand that the Internal Revenue Code and the
HCFSA Plan Document are the final authority in determining eligible expenses.
Date ______/______/______
Signature ________________________________________________________________________________________________
Did you remember to:
 Complete all sections?
 Choose the correct claim period?
 Sign and date the form?
 Attach EOB statement(s), bill(s) and appropriate documentation?
:
:\
\
\
\
_
_
.
2017
2017_
09/16
j
pretax
fsa
plyr
hcfsa
hcfsa
claim
frm
indd

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