Fsa Medical Expense Reimbursement Claim Form - A1hr
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1FSA Medical Expense Reimbursement Claim Form
Please check:
Medical
Dental
Employee Information
Employee Name
Social Security #
Address
Worksite Employer
Claim Information*
Date of Service
Provider Name
Patient Name
Relationship to
Service Provided
Requested
Employee
Amount
$
I certify that the expenses for which I am seeking reimbursement from the FSA have been incurred by me or by an
individual who qualifies as my spouse or my dependent for federal income tax purposes during the current plan year. I
further certify that these expenses have not been reimbursed, nor shall reimbursement be sought from any other health
plan coverage. I also certify that I have not, and will not claim a tax deduction or credit for these expenses on my federal
income tax return, or on my state or local tax returns in violation of state or local law. I agree to submit and retain
sufficient documentation for any expense for which I seek reimbursement.
Employee Signature: ___________________________________
Date: _____/_____/____
*Acceptable documentation:
1. An itemized billing from the medical provider
2. EOB (Explanation of Benefits)
3. Receipt for eligible items
For Orthodontia Claims:
When submitting your first orthodontia claim, you must submit the orthodontia contract along with a signed FSA Health Care
Reimbursement form. This contract should indicate initial fee charged, estimated insurance payment, initial start date, duration of
treatment and proof of partial or full down payment.
For each monthly request for reimbursement, you must submit a completed claim form with an itemized bill from the orthodontist.
The statement should show the monthly charge consistent with the original orthodontic contract.
Submitted claims will not be returned.
Please refer to more information on FSA medical expenses
Submit claims to: A1HR, 3829 Coconut Palm Drive, Tampa, FL 33619
A1HR Phone: 813-620-1661 Toll Free: 877-636-1661 Fax: 813-490-1191
FSAMed 201510
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