Fillable Health Expense Reimbursement Request Form printable pdf download

MAIL TO:

Blue Cross and Blue Shield of Florida

Spending Account Administration

P.O. Box 45132

Jacksonville, FL 32232-5132

(800) 753-4681

Health Expense

Reimbursement Request Form

For Health Care Flexible Spending Accounts (FSAs) and Health Reimbursement Accounts (HRAs)

PLEASE PRINT AND COMPLETE THIS FORM IN ITS ENTIRETY. INCOMPLETE FORMS WILL BE RETURNED.

Complete the information below for out of pocket Health Care Expenses incurred by you and your eligible dependents. Eligible dependents are defined

by your employer and must meet the definition of dependent as defined by the IRS for tax reporting purposes. You must provide an Explanation of

Benefits from your Health Plan, if applicable, indicating the amount of the expense you are obligated to pay or a written statement, bill or receipt from

an independent third party, such as an insurance company, doctor or other health care provider, indicating the date and type of medical expense that

has been incurred and the amount of such expense (canceled checks will not be accepted). Only list the amounts you have to pay, (your out-of-pocket

expense), after insurance, if applicable, pays its share. Please sign and date the form, then send it along with your proof of expense documentation.

Balance forward/due or generic “cash receipts” are not acceptable.

Employee’s Name: (Last Name, First Name, Middle Initial)

Social Security Number:

Employer’s Name:

Specify which account(s) you participate in:

Health Care FSA

HRA

Both

Type of Health Plan(s). Check all that apply:

PPO Health

HMO Health

Pharmacy

Dental

Vision

None

Other: Please specify___________________________

Note: If unsure, you may enclose a copy of your ID card(s).

Dependent Information

Are any of your dependents college students under age 25?

Yes

Does the dependent(s) you are claiming live in your household?

Yes

Do you provide more than one-half of the support for the dependent(s) during the year?

Yes

Reimbursement For Health Care Expenses

Patient / Dependent’s

Birth

Relationship

Date of

Out-of-Pocket

Type of Service

Name of Service

BCBSF

First

Last Name

Date

To Employee

Service*

Amount

Provider

Use Only

Example: Pat Roe

10/3/55

Self

4/9/02

$ 15.00

Doctor Visit

Dr. John Smith

*Service must be totally rendered and completed before

TOTAL

0.00

payment on any part can be made.

Employee Signature Required Below

I certify that all expenses for which reimbursement or payment is claimed by submission of this form, were incurred during a period while I was a

participant under my company’s Flexible Spending Account (FSA) and/or Health Reimbursement Account (HRA) plans administered by Blue Cross and

Blue Shield of Florida (BCBSF); and that such expenses have not been reimbursed, and are not reimbursable, under any other health plan coverage,

other insurance, or from any other source. I understand that if I participate in both the Health Care FSA and the HRA plans that reimbursement will be

made from the FSA first, when the expense is eligible under both plans. I understand that I alone am fully responsible for the sufficiency, accuracy and

veracity of all information I provide relating to this reimbursement request; and that unless an expense for which reimbursement is claimed is a proper

expense under the Plan, I may be liable for the payment of all related taxes including Federal, state or city income on paid amounts which relate to

such expense. I further understand that no separate Federal income tax deduction or credit is permitted for amounts for which reimbursement is made.

I hereby authorize any individual or organization to release any information requested by BCBSF with respect the claims on this specific application.

Employee Signature: __________________________ Day Phone #: ________________ Date: _______

FOR BCBSF USE ONLY

Processor’s Name: ________________________ Request ID: _____________________ Date Processed: _____________

62954-1005R SR

Health Expense Reimbursement Request Form

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