Fsafeds Health Care Fsa Claim Form Page 3
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1
2
3USE THIS PAGE FOR ADDITIONAL HEALTH CARE EXPENSES.
HKLUMD
SECTION 4: EMPLOYEE INFORMATION (ABBREVIATED)
EMPLOYEE USER ID (NO DASHES)
2 1 6 4 6 4 4 5 8
EMPLOYEE LAST NAME
EMPLOYEE FIRST NAME
S C H E I G
WILLIAM
SECTION 5: YOUR ADDITIONAL HEALTH CARE EXPENSES
EXPENSE 3
DATES OF SERVICE
AMOUNT REQUESTED (DOLLARS . CENTS)
FROM (MMDDYY)
.
$
Please Select Code
SUPPORTING
DOCUMENTATION ATTACHED?
COVERAGE CODE
(SEE PAGE 1)
FAMILY MEMBER’S NAME
TO (MMDDYY)
YES
NO
EXPENSE 4
DATES OF SERVICE
AMOUNT REQUESTED (DOLLARS . CENTS)
FROM (MMDDYY)
.
$
Please Select Code
SUPPORTING
DOCUMENTATION ATTACHED?
COVERAGE CODE
(SEE PAGE 1)
FAMILY MEMBER’S NAME
TO (MMDDYY)
YES
NO
EXPENSE 5
DATES OF SERVICE
AMOUNT REQUESTED (DOLLARS . CENTS)
FROM (MMDDYY)
.
$
Please Select Code
SUPPORTING
DOCUMENTATION ATTACHED?
COVERAGE CODE
(SEE PAGE 1)
FAMILY MEMBER’S NAME
TO (MMDDYY)
YES
NO
EXPENSE 6
DATES OF SERVICE
AMOUNT REQUESTED (DOLLARS . CENTS)
FROM (MMDDYY)
.
$
Please Select Code
SUPPORTING
DOCUMENTATION ATTACHED?
COVERAGE CODE
(SEE PAGE 1)
FAMILY MEMBER’S NAME
TO (MMDDYY)
YES
NO
EXPENSE 7
DATES OF SERVICE
AMOUNT REQUESTED (DOLLARS . CENTS)
FROM (MMDDYY)
.
$
Please Select Code
SUPPORTING
DOCUMENTATION ATTACHED?
COVERAGE CODE
(SEE PAGE 1)
FAMILY MEMBER’S NAME
TO (MMDDYY)
YES
NO
USE AN ORIGINAL FORM (NOT A PHOTOCOPY)
HKLUMD
Page 3 - HEALTH CARE CLAIM FORM
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