Fsafeds Health Care Fsa Claim Form printable pdf download

HOW TO REQUEST REIMBURSEMENT FROM YOUR HEALTH CARE ACCOUNT

Use this form to request reimbursement for your health care expenses only. To view a detailed list of eligible medical expenses, visit

FSAFEDS Eligible Expenses Juke Box

at Remember, you should first submit health care expenses under your FEHB or other

health care plan you may have before you request reimbursement from your Health Care Flexible Spending Account.

Use this form only to request reimbursement for:

• Allowable expenses covered, but not fully reimbursed, by any benefit plans. Attach a copy of the plan’s Explanation of Benefits Statement (EOB)

or itemized receipt from your provider.

• Allowable expenses not covered by any benefit plans. Attach bills or receipts which indicate the name and address of the provider of the product or

service and description of the product or service provided.

Step 1: Fill out the form

Type of Supporting Documentation:

Please type or print in capital letters, with your letters centered in the boxes provided and fill in all ovals

• Itemized receipt from your medical, dental

as shown:

or vision provider or pharmacy

A B C D

1 2 3 4

• Itemized receipt for over-the-counter

YES

medicines – must show the name of the

product

• Explanation of Benefits (EOB) from your

For Section 1: Complete all areas of “Employee Information.” You may use your User ID instead of your SSN in

insurance company or health care provider

part 1 of the claim form. You will receive an email confirming receipt of your claim.

• Documentation must show:

For Sections 2 & 5: Fill in your expense – you can use one line to show a total of multiple expenses

Date expense was incurred

•

within the same Coverage Code.

Type of service or name of product

•

• Complete all sections of the form. Sign and date the bottom of the form.

Amount (your portion of payment)

•

• Please use page 3 for additional expenses if you exceed the number of lines provided on page 2.

Person or organization providing the

•

service and product

Step 2: Attach supporting documentation

In addition to completing the form, you must submit the documentation described under either

A or B below:

Helpful Hints:

A. Explanation of Benefits Form (EOB): This is the form you receive each time you or a health care

provider submit medical, dental or vision claims for payment to your health, dental or vision care plan. The

• Add together similar expenses from the same

EOB will show the amount of expenses paid by the plan and the amount you must pay. For expenses that

Coverage Code and place that total on one

are partially covered by your (or your dependent’s) medical, dental or vision plans, you must attach the

line (e.g., several over-the-counter items –

EOB. Please refer to the list of codes below.

Code 102, multiple prescription copays –

Code 103, etc.)

B. All Other Expenses: For expenses not covered at all by your (or your dependent’s) medical, dental or

Provide the span of dates of service

vision plans, your claim must include acceptable evidence of your expenses.

•

(e.g. 01/01/08 - 06/30/08)

A cancelled check is not considered acceptable evidence. Acceptable evidence includes receipts which con

Enter the total amount on one line

tain the following information:

•

Be sure to include legible receipts for each

• Type of service or product provided

•

expense included in the overall total

• Date expense was incurred

• Person or organization providing the service and product

• Be sure to use your FSAFEDS UserID

• Amount of expense

• Be sure your signature is legible

If your receipt does not clearly show the name of the product or service provided, you must submit

• Be sure copies of OTC labels, if required, are

copies of the Universal Product Code (UPC) and copies of the front label on the box/container for over-the-coun

clear enough to fax

ter (OTC) products and services.

• The Total Requested box will automatically

Step 3: Read the Certification and then sign and date the form where indicated

calculate the sum of expenses you list on

page 2, or pages 2 and 3.

Step 4: Submit your form

• By Fax: Fax the form and supporting documentation to 1-866-643-2245 (toll-free). If you are sending from

outside the United States, please fax to 1-502-267-2233.

Please Do NOT :

• By Mail: Place the form and the supporting documentation into an envelope, apply the correct postage,

• Use red ink

and mail to FSAFEDS Program, PO Box 36880, Louisville, KY 40233.

• Use a photocopy of this form

• Keep a copy of your completed form and receipts for your records.

• Use a highlighter on your receipts or any

Please remember that FSAFEDS has a minimum reimbursement threshold of $25.00. If your claim does not

part of the form

total $25.00, it will be processed and you will receive a reimbursement statement, but your payment will be

• Staple your copied receipts to the form

pended until you submit another claim and reach the $25.00 aggregate amount, or until the end of the

• Write outside the boxes provided

quarter, whichever comes first.

• Fax the same form more than once

• Mail the same form that you have faxed

• Include this instruction sheet with your fax

COVERAGE CODES – You must include a code in Sections 2 and 5 of the form.

Please DO:

Dental code

Medical codes

• Circle applicable items on your receipts

102 = over-the-counter items

202 = general dental (e.g., cleanings, x-rays,

(just don’t use a highlighter)

crowns, implants, dentures - or use 102 for

103 = prescriptions or prescription co-pays

• Use as many sheets for additional expenses

over-the-counter items)

104 = general medical (e.g., co-pays, deductibles)

as you need

203 = orthodontia

120 = mileage

• Use code 999 for any eligible item that isn’t

covered by one of the other Coverage Codes

Vision code

Other code

303 = general vision (e.g., exams, glasses, contact

999 = other

lenses - or use 102 for over-the-counter items)

Questions? Need a list of

eligible

expenses? Go to

or contact an FSAFEDS Benefits Counselor at 1-877-FSAFEDS.

Page 1 - HEALTH CARE CLAIM FORM

Fsafeds Health Care Fsa Claim Form

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