Claims Form - Fsa Dependent Care Page 2

P.O. Box 520, Euless, TX 76039 Phone: (817) 731-6258

Fax: (817) 731-9029 Email: Website:

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM

NAME_____________________________________ EMPLOYER_________________________________________ SSN ________-______-________

HOME (MAILING) ADDRESS_______________________________________________ CITY____________________ STATE______ ZIP__________



check here if your address has recently changed

EMAIL ADDRESS ___________________________@_________________________________ DAY PHONE (_____) _______-__________ (optional)

Is your proof of expense & payment attached?

Yes No

SUMMARY OF EXPENSES

Payment

Dates of Service

Employee’s

Provider Tax ID or SSN

Responsibility

Relationship

(Signature of Provider

From

To

(Reimbursement

Name of Individual Receiving Services

Age & Grade

to Employee

Service Provider Name & Address

is Required on Receipt)

MM/DD/YY

MM/DD/YY

Amount)

Claims must be filled out completely and received by 12pm prior to the processing day in order to obtain reimbursement during the next processing cycle.

TOTAL

Please note your check will be mailed or direct deposit uploaded on the processing day, however please allow 3-5 business days to receive payment.

I (above named Participant) understand and agree that:



These expenses are not reimbursable from any other health plan, insurance or other source, and will not be used to claim any federal income tax deduction or credit.



The Unreimbursed Medical expenses listed above would be deductible medical expenses under Internal Revenue Code Section 213 and are allowed under Prop. Treas. Reg. 1.125-2;



If the expense is for my spouse or dependent, I certify that the person listed is my spouse or meets the definition of dependent under the plan as defined in Code Section 152;



By submitting this information (via fax, e-mail, or any other media), I am responsible for any inappropriate use or disclosure that may occur due to incorrect or inaccurate transmissions;



I authorize the Plan and its service provider, their respective agents, employees, sub-contractors and assigns to use and/or disclose the information provided above as they reasonably deem necessary to manage the Plan (including but not limited to, disclosures to my employer for Plan

Administration purposes such as the evaluation of eligibility for reimbursement under the Plan) and to detect or prevent fraud or misrepresentation;



I authorize any provider, insurer, or other entity to release any health or treatment information for the purpose of determining eligibility for Plan benefits or to detect or prevent fraud;



I give up any claims related to the use, disclosure, or release of this information so long as the information is used for the purposes defined above; and



.

This authorization does not in any way limit any right that ER/PSP, their respective agents, employees, sub-contractors, and/or any assigns may have under applicable state or federal law or regulation regarding the use of such information

EMPLOYEE SIGNATURE: _______________________________________________________________

DATE: _________________________________________