Spending Account Claim Form Page 2
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1
2You can submit this data via
myameriflex.
u
Spending Account Claim Form
STEP 1
Employer Name:
Employee Name:
SSN:
Phone:
Email:
STEP 2
Medical Expense Claims (FSA, or Employer funded HRA)
Account Type
Name of Person
Provider Name
Service Provided
Date
Amount
Expense Incurred
Receiving Medical Service
(Physician, Hospital, Dentist, Pharmacy, etc.)
(Co-Pay, Deductible, Dental, Vision, RX, over-the-counter, etc.)
Requested
FSA
HRA
Dependent Day Care Claims
Dependent Name
Dependent
Date of Service
Provider Name
Provider
Type of Service
Amount
DOB
From
To
Tax ID #
(Day Care, Pre-K, Day Camp, etc.)
Requested
Provider Signature or Stamp
(if no receipt is available)
Other Claims
(ex: PRM, EPR, PKG, etc.)
Expense Type
Date(s) of Service
Provider Name
Description of Expense
Amount
(Name of provider)
Other
From
To
(Any other expenses you may have, etc.)
Requested
Form cannot be processed without valid signature
STEP 3
By signing this document I agree to the terms and conditions detailed in the instructions provided on page one.
Employee Signature
Date
Please email, fax, or mail to:
Email
Fax
Mail
888.631.1038
Ameriflex Claims Department
Attention: Claims Department
P .O. Box 269009
Plano, TX 75026
Please do not send original documents.
If damaged or lost during processing,
they cannot be replaced.
8 8 8 . 8 6 8 . F L E X ( 3 5 3 9 )
T O L L
F R E E :
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