Health Flexible Spending Account (Fsa) Reimbursement Request
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2P. O. Box 4346
Missoula, MT 59806
HEALTH FLEXIBLE SPENDING ACCOUNT (FSA)
REIMBURSEMENT REQUEST
To send scanned claims, or for additional forms, go to:
FAX: 406-523-3149 or toll-free 877-424-3539
PHONE: toll-free 877-424-3570
Please print legibly in black or blue ink.
Employer Name: __________________________
Total # of Pages Submitted: _____
Employee Name: _________________________
Attention: ____________________________
Participant ID: ____________________________
Comments: ___________________________
(Social Security Number or, if assigned, Allegiance ID)
You may check the status of your claim, within 48 hours, by logging in to your account at
. If you have not received reimbursement within two weeks, please contact an
Allegiance representative at 877-424-3570.
If you would like future payments directly deposited into your bank account, include a voided check with
this form or sign up on the Allegiance website.
PLEASE SEE REVERSE FOR CLAIM FILING INSTRUCTIONS. List the medical, dental or vision services and expenses for
you and your family that you have to pay after insurance pays its share. Insurance premiums are not eligible.
AMOUNT
TYPE OF EXPENSE
SERVICE DATES
REQUESTED
________
________
________
Medical Reimbursement Requested ***
From
To
$
________
________
________
Prescription Reimbursement Requested
From
To
$
________
________
________
Vision Reimbursement Requested
From
To
$
________
________
________
Dental Reimbursement Requested
From
To
$
________
________
________
Orthodontia Reimbursement Requested
From
To
$
(Ortho contract available on website.)
________
TOTAL REIMBURSEMENT REQUESTED
$
Include independent, third-party documentation of your expenses with this claim form. If any of these expenses were covered by insurance, attach a copy of
the explanation of benefits (EOB) from your insurance company. For expenses that are not eligible for submission to insurance, send a copy of a bill or
invoice identifying the service, service date, and total charges. If required documentation is not attached, your reimbursement may be delayed.
I certify that the claimed expenses were incurred to diagnose, cure, treat, mitigate, and/or prevent a disease and cover only myself, my qualified dependents,
and/or spouse. These expenses have not previously been reimbursed under any plan and I will not seek reimbursement under any other health plan. I
understand that items purchased merely to promote general health are not reimbursable. I further understand that expenses reimbursed through my health
FSA may not be claimed on my individual tax return.
________________________________________
____________________
Signature (required):
Date:
□
______________________________________
Check here if your address has changed. New address:
Please inform your employer if your address has changed.
_________________________________________________________
***Over-the-counter drugs and medicines are not reimbursable unless prescribed by a medical practitioner.
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