Form Clm-113 - Health Flexible Spending Account Fsa Claim Form printable pdf download

Form Clm-113 - Health Flexible Spending Account Fsa Claim Form

Health Flexible Spending Account (FSA)

Claim Form

INSTRUCTIONS

1. Please see the reverse side for instructions on completing this claim form.

2. Please PRINT all requested information (except signature).

3. Please retain a copy of this completed form and documentation for your records.

PAYMENT OR REIMBURSEMENT OF HEALTH FSA CLAIMS ARE SUBJECT TO THE PROVISIONS OF YOUR EMPLOYER’S PLAN DOCUMENT

AND APPLICABLE LAWS AND REGULATIONS.

Employee’s Name - Last, First, Middle Initial

Employee’s Social Security Number

Email Address

q Check this box if this is a new address.

Address

Daytime Telephone Number - Include Area Code

Employer

The terms health care expenses, claims, insurance and employer-sponsored

If you have any questions:

health care program include expenses, claims, insurance and employer-

Visit: (select Pre-Tax Beneﬁts Program)

sponsored programs for medical, dental, vision and prescription drugs.

Email:

Use this form to request reimbursement only for the following:

Call: 302.421.8970 or 800.559.FLEX (3539), 8:00 AM-5:00 PM

1. Expenses not covered by any health insurance; and

(ET), Monday-Friday

2. The unpaid balance of a health care claim, including, but not limited to,

Fax for questions or Claims: 302.421.8883

any copayments, coinsurance or deductibles.

DATE OF

EXPENSE

PROVIDER OF SERVICE

PERSON RECEIVING SERVICE

BIRTH DATE

RELATIONSHIP

SERVICE

REIMBURSEMENT

TYPE

REQUEST AMOUNT

FROM - TO

CODE*

Signature:

Date: _______/_______/_______

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, ﬁles a claim containing any false, incomplete or misleading information may be guilty of a felony.

Attach copies of the required documentation to this form and send to:

Highmark Blue Cross Blue Shield Delaware

Flexible Beneﬁts Department

P.O. Box 8737

Wilmington, DE 19899-8737

CLM-113 (6-12)

Form Clm-113 - Health Flexible Spending Account Fsa Claim Form

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