Flexible Spending Account Reimbursement Claim Form
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1
2Please attach the required documentation to this form and send to:
(See back of form for explanation of required documentation)
Stanley, Hunt, DuPree & Rhine, Inc.
Employer ________________
Post Office Box 6400
Greenville, SC 29606
OR
Fax number 1-252-293-9048 or 1-252-293-9049
Number of pages in this fax _____
OPTIONS FOR OBTAINING ACCOUNT INFORMATION:
Flexible Spending Account
website
Interactive Voice Response 1-800-413-6706
Reimbursement Claim Form
1-800-930-2441 or 1-800-768-4873 (Monday thru Friday 8:00 a.m.–6:00 p.m. ET)
Employee Name:
Social Security Number:
Daytime Phone Number:
Email:
Health Care Expenses
(1) I have insurance for this expense. Attach a copy of the explanation of benefits (EOB) statement that you received from your insurance carrier showing how
benefits were paid. IMPORTANT NOTE: IF YOU HAVE GROUP INSURANCE COVERAGE BUT DO NOT SUBMIT AN EOB OR AN ITEMIZED
STATEMENT SHOWING THE PORTION PAID BY INSURANCE YOUR CLAIM WILL BE DENIED. If the documentation provided clearly shows that
the expense is for a co-pay, an EOB is not required.
(2) I do NOT have insurance coverage for this expense. Submit an itemized statement showing the date of service, provider’s name, patient name, services
provided, and the amount of the charge.
For the Benefit of
Date Expenses
*Expense
Reimbursement
Service Provider
(Name)
Relationship
Incurred
Type
Request Amount
$
$
$
*Expense Type Code: D-Dental H-Hearing V-Vision P-Prescription M-Misc./Medical O-Orthodontia
Total Health Care
Please see back of form to add more claims.
Reimbursement Requested $_______________(A)
Dependent Care Expenses
Service Provider
Dependent Name
Date Expenses
Reimbursement
and Tax ID or SSN
and Age
Relationship
Incurred
Request Amount
$
$
$
Total Dependent Care
Reimbursement Requested $________________________(B)
TOTAL REIMBURSEMENT REQUESTED $______________________(A+B)
I certify that the charges listed for dependent day care services have been incurred for the dates shown.
_________________________________________
______________________ __
__________________________________________
Signature of Provider
Date
Tax ID #/SSN
Where I have not included the taxpayer identification number or social security number of each dependent day care provider listed above, I have done so because of
one of the following reasons: The provider is a nonprofit religious, charitable, or educational organization [under Code Section 501(c) (3)]; or I was unable to obtain
this information after diligently trying to obtain it.
Employee Signature_____________________________________________________________ Date______________________
Employee Certification
1.
The health care expenses claimed above are not eligible for reimbursement by any insurance carrier or employer-sponsored plan.
2.
The dependent care expenses claimed above are employment-related, have not been paid to a dependent, and are not greater than either my earned income
or my spouse’s earned income.
3.
The expenses claimed above have not been and will not be taken as a credit or deduction on my personal income tax return.
Employee Signature____________________________________________________________ Date______________________
Claims cannot be processed without the participant’s signature.
See back for instructions on completing this form.
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