Flexible Spending Account (Fsa) Request For Reimbursement Form
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2FLEXIBLE SPENDING ACCOUNT (FSA)
REQUEST FOR REIMBURSEMENT FORM
Employer _______________________________________________________________________________________________
Employee Name _____________________________________________________ Soc.Sec.No. _________________________
Last
First
M.I.
Home Address ___________________________________________________________________________________________
Number/Street
City
State
Zip
Daytime Telephone Number _______________________________ E-mail Address ___________________________________
Please check only if this is a new address
Direct Deposit Authorization – Please complete this section to have your FSA reimbursements direct deposited into your
checking or savings account. This is a faster, more secure method of reimbursement. If you are already set up for direct deposit,
there is no need to complete again. You may attach a voided check if you are unsure of your routing and/or account number.
Name of Banking Institution:
Routing Number:
Account Type:
Checking
Savings
Account Number:
HEALTH FSA
(See documentation requirements and guidelines on reverse side of claim form)
Date
Amount of
Patient’s Name & Relationship
of Service
Description of Service
Provider of Service
Reimbursement
Total Expenses $_______________
DEPENDENT CARE FSA
Please attach a receipt or statement from your dependent care provider showing the “from/through” dates of service, or have your provider
sign the receipt on the back of this form. Please note: services must actually be rendered prior to requesting reimbursement (see reverse).
Date of Service
For the Benefit of
Amount of
From mo/day/year to mo/day/year
(Name and Relationship)
Provider of Service
Reimbursement
____/____/____ to ____/____/____
____/____/____ to ____/____/____
____/____/____ to ____/____/____
____/____/____ to ____/____/____
Total Expenses $_______________
I certify that I have not previously requested reimbursement for the above expense under this plan or any other plan, and I will not seek
reimbursement from any other health plan coverage or any other source. I also certify that the expenses were incurred by me and/or my
eligible dependents, and will not be applied toward any federal or state income tax deduction or credit.
_____________________________________________________________________________________________________________
Employee Signature
Date
Note: You may now submit claims online through this our online access at No claim forms are required!
Contact Arcadia or your HR Dept. for the Employer Code you need to register.
Arcadia Benefits Group, Inc. 612 S. Park St., Kalamazoo, MI 49007
Phone: 269-744-3431
Toll Free: 866-329-4333
Fax: 269-381-5844
E-mail:
Rev. 10/13
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