Flexible Spending Account (Fsa) Claim Form printable pdf download

Instructions for completing your Flexible Spending Account Claim Form

Medical Reimbursement Claim Instructions

Before sending in a claim for medical expenses, first submit all of your expenses through your employer’s

group health carrier. You will receive an “EOB” (Explanation of Benefits) from the carrier. This explanation will

show what portion is ineligible for payment under the insurance program and, therefore, eligible for

reimbursement through your medical reimbursement plan. If you are requesting reimbursement for expenses

for which you have no insurance coverage (e.g., dental, vision, or hearing), simply complete the claim form and

mail or fax with the bill or receipt. The receipt should list dates of service, paid charges, and services provided.

Dependent Care Reimbursement Claim Instructions

You must submit a receipt or statement from the provider of the Dependent Care service. This document must

show the dates of service and the name of the dependent for whom care is provided. Expenses may not be

submitted until the services are provided. Please note that AmeriFlex requires the following information on

each reimbursement request: name of day care provider and tax ID#, dates of service, and type of service (i.e.

“day care”). If the receipt is not a printed form with the name of the day care provider, said provider must sign

it. Dependent Care expenses are reimbursable when the service is provided, not when the bill is paid. If you

prepay for an entire month, the claim will be separated into weekly segments as the service is rendered.

Submission Procedures

For your convenience, claims can be mailed or faxed. When sending your claim, please be sure to fax or

enclose copies of appropriate bills, receipts, or EOBs (cancelled checks or credit card statements will not be

accepted) pertaining to that claim. Please be sure to sign and date each claim submitted. If the claim form is

not complete, your reimbursement request cannot be processed.

Mail Claims to:

Fax Claims to:

AmeriFlex, LLC

Claims Department

303 Fellowship Road

856-631-1020

Suite 201

Mount Laurel, NJ 08054

AmeriFlex, LLC • 303 Fellowship Road, Suite 201 Mount Laurel, NJ 08054

888.868.FLEX (3539) • Fax 856.631.1020 •

Flexible Spending Account (Fsa) Claim Form