Fsafeds Health Care Fsa Claim Form (Page 2 of 3) in pdf

MAIL: FSAFEDS Program

HEALTH CARE CLAIM FORM

PO Box 36880

Use only CAPITAL LETTERS

WKBVDY

Louisville, KY 40233

FAX TO: 1-866-643-2245 TOLL-FREE or 1-502-267-2233

PHONE: 1-877-FSAFEDS

For additional expenses, please use next page.

(1-877-372-3337)

TTY:1-800-952-0450

SECTION 1: EMPLOYEE INFORMATION

EMPLOYEE USER ID (NO DASHES)

PROGRAM NAME

FOR SHPS USE

FSAFEDS

2 1 6 4 6 4 4 5 8

EMPLOYEE LAST NAME

EMPLOYEE FIRST NAME

S C H E I G

WILLIAM

EMPLOYEE EMAIL

DAYTIME PHONE # (AREA CODE FIRST, NO DASHES)

Wscheig@hrsa.gov

3 0 1 4 4 3 4 3 2 2

SECTION 2: YOUR HEALTH CARE EXPENSES

EXPENSE 1

DATES OF SERVICE

AMOUNT REQUESTED (DOLLARS . CENTS)

FROM (MMDDYY)

General vision (exams, glasses, contact lenses)

0 3 1 7 1 0

0 1 9 9

0 0

SUPPORTING

DOCUMENTATION ATTACHED?

COVERAGE CODE

(SEE PAGE 1)

FAMILY MEMBER’S NAME

TO (MMDDYY)

YES

0 3 1 7 1 0

SELF

EXPENSE 2

DATES OF SERVICE

AMOUNT REQUESTED (DOLLARS . CENTS)

FROM (MMDDYY)

0 1 9 9

0 0

0 3 1 7 1 0

General vision (exams, glasses, contact lenses)

SUPPORTING

DOCUMENTATION ATTACHED?

FAMILY MEMBER’S NAME

TO (MMDDYY)

COVERAGE CODE

(SEE PAGE 1)

YES

0 3 0 7 1 0

SELF

TOTAL REQUESTED (SUM OF EXPENSES FROM ALL PAGES SUBMITTED)

SECTION 3: CERTIFICATION

Please read carefully before signing.

398.00

I affirm that:

• I HAVE NOT ALREADY BEEN PAID FOR THESE EXPENSES FROM MY FSA AND I HAVE NOT REQUESTED and WILL NOT RECEIVE REIMBURSEMENT FOR

THESE EXPENSES FROM ANY OTHER PLAN INCLUDING FEDVIP (Federal Employees Dental and Vision Insurance Program) and FEHB (Federal Employees

Health Benefits Program); AND

• I have submitted the above information in good faith and it is correct to the best of my knowledge.

I understand that:

• Reimbursement is not a guarantee that this payment is tax-free.

• The service(s) for which I am requesting reimbursement must be incurred during my period of coverage, which begins the next January 1 if I enrolled

during the Open Season, or the day after my enrollment is accepted by FSAFEDS, whichever is later, and ends no later than March 15 of the following

year, unless my coverage ends sooner due to a Qualifying Life Event.

• I have until April 30 following the end of the Benefit Period or end of Federal Service to submit my claim for reimbursement of eligible expenses

incurred during my period of coverage. If I do not submit claims for reimbursement by that date, I will forfeit any funds remaining in my account(s) in

accordance with IRS rules.

• I cannot use health care expenses reimbursed through my general purpose HCFSA or LEX HCFSA as a deduction on my personal income tax return.

I authorize release of payment through my Flexible Spending Account. I authorize FSAFEDS, or its representatives, to obtain necessary information from

all physicians, hospitals, medical service providers, pharmacists, employers, and all other agencies or organizations (including other insurers) to consider

the claim for reimbursement under my Flexible Spending Account.

Employee Signature*

Date

(MMDDYY)

*Your signature and date are required in order to process your claim for reimbursement.

USE AN ORIGINAL FORM (NOT A PHOTOCOPY)

WKBVDY

Page 2 - HEALTH CARE CLAIM FORM