Flexible Spending Account Claim Form - Health Economics Group printable pdf download

FLEXIBLE SPENDING ACCOUNT CLAIM FORM

Please read these instructions before completing the claim form:

1. Employee must complete Part I. (If applicable, complete Part II and/or Part III).

2. Instructions for Part II “Health Care Expenses”:

Check which account box you would like this claim to be paid from.

A. Expenses covered by your spouse’s or your health care plan(s) must be submitted to that/those plan(s) prior to submission to your flex medical reimbursement

account. Attach a copy of the explanation of benefits statement or itemized bill showing health care plan(s) payment(s) in order to claim your patient responsibility

amounts.

B. For all other eligible health care expenses, attach an itemized receipt that clearly states the name and address of the provider, date of service, service rendered, name

of person receiving the service and the amount charged

3. Instructions for Part III “Dependent Care Expenses”: Attach a copy of a receipt that includes the Federal ID# or SS# of the provider, name and address of the provider,

name of dependent receiving the service, amount paid, and date (or date range) the service was provided. Federal form W-10 for each dependent care provider must be

on file in our office.

4. Read the Employee Statement, sign and date the form.

5. Mail (or fax) the completed form to the address (or fax number) provided on this form.

Part I: Employee Information

(Please Print)

Employer Name:

Employee Name:

Employee Social Security Number:

Address:

New Address?

YES

Daytime Phone

Evening Phone

Part II: Health Care Expenses

Date of

Amount

Administrative

Covered Person

Service

Provider

Claimed

Use Only

Medical Expenses Subtotal

Part III: Dependent Care Expenses (Day Care Services)

Date of

Date(s) of Service

Amount

Administrative

Dependent Name

Birth

Provider

MM/DD/YYYY

Claimed

Use Only

From:

To:

From:

To:

From:

To:

Dependent Care Expenses Subtotal

Total Amount Claimed

Employee Statement:

I request payment from my Cafeteria/Flexible Benefits Account(s) for the expenses itemized on this claim form. I certify that I have not received reimbursement under this Plan

or from any other source for these expenses and that I will not seek additional reimbursement for the amount(s) paid by this Plan. I further certify that I have met all

requirements for eligible expenses under this Plan. I understand that expenses for which I have been reimbursed cannot be claimed on my personal income tax return.

Employee Signature: _____________________________________________________________ Date: ____________________________________

Send completed claim form to:

Health Economics Group, Inc.

(585) 241-9500, ext. 504

1050 University Avenue, Suite A

(800) 666-6690, ext. 504

Rochester, NY 14607

FAX: (585) 241-9518