Request For Reimbursement Form
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1
2REQUEST FOR REIMBURSEMENT
Instructions: FAILURE TO COMPLETE ALL SECTIONS OF THE FORM MAY DELAY THE PROCESSING OF YOUR CLAIM. Please print or type the requested information. For all types of claims,
complete Part I of the form. Complete Part II for any medical/dental/optical/over the counter type of expenses. Complete Part III for any dependent daycare expense. You MUST document each expense
by either attaching itemized receipts or have the provider complete the provider certification section (daycare only). Attach copies (do not send originals) of the receipts for each expense showing who the
service is for, the provider or store name, the incurred date (not paid date), the amount, and the nature of the expense. If you are submitting more than one expense, number the receipt copy to correspond
to the line number on which the expense is listed. Sign and date the form. Please make a copy of this form for your records and send the original with attached receipts to:
Corporate Health Systems, Inc. Attn: Reimbursement Claims P.O. Box 46390 Eden Prairie, MN 55344-6390 or Fax to (952) 939-0990 ~ Phone (952) 939-0911
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MPLOYEE
NFORMATION
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_________________________________________________
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______________________________________________
MPLOYEE
AME
MPLOYER
AME
Last 4 Digits of Social Security Number_____________________________
Daytime Phone Number _______________________________________
A
_______________________________________________________
C
/ S
/ Z
________________________________________
C
DDRESS
ITY
TATE
IP
HECK IF NEW ADDRESS
P
II
M
/ D
/ O
/ O
T
C
E
ART
EDICAL
ENTAL
PTICAL
VER
HE
OUNTER
XPENSES
P
’
N
S
D
R
N
E
O
(Doctor, Dentist, Etc.)
ROVIDER
S
AME
ERVICE
ATE
EQUESTED
ATURE OF
XPENSE
FFICE
L
P
R
S
O
C
P
(M
/D
/Y
)
A
O
N
P
U
(Store Name)
INE
ERSON
ECEIVING
ERVICE
VER THE
OUNTER
RODUCTS
O
AY
R
MOUNT
R
AME OF
RODUCT
SE
1
2
3
4
5
6
7
8
T
A
R
:
OTAL
MOUNT
EQUESTED
P
III
D
D
E
ART
EPENDENT
AYCARE
XPENSES
D
’
N
S
D
R
R
A
P
’
C
C
L
O
EPENDENT
S
AME WHO IS
ERVICE
ATE
ANGE
EQUESTED
GE OF
ROVIDER
S
ERTIFICATION OF
LAIM
INE
FFICE
L
D
P
’
N
(M
/D
/Y
- M
/D
/Y
)
A
D
S
E
A
U
INE
RECEIVING THE SERVICE
AYCARE
ROVIDER
S
AME
O
AY
R
O
AY
R
MOUNT
EPENDENT
IGNATURE AND
XPENSE
MOUNT
SE
1
/$
2
/$
3
/$
4
/$
5
/$
T
A
R
:
OTAL
MOUNT
EQUESTED
I certify the above information is correct and the expenses claimed were incurred by me or my eligible dependents after my effective date of coverage in my employer’s reimbursement benefit plan but prior
to the end of my employer’s plan year. I certify these expenses are not eligible for reimbursement under any other plan, and comply with the requirements of this plan. I have not and will not claim these
expenses on my personal income tax return. I certify, to the extent required by federal law, that I will file the designated form with the IRS by April 15 of the year after the expenses were incurred.
E
S
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MPLOYEE
IGNATURE
ATE
FSA FORM 001 – 01/2011
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Parent category: Medical