Bswift Request For Reimbursement Form – Fill Out and Use This PDF

The Bswift Request for Reimbursement Form is a crucial document for employees participating in a Flexible Spending Account (FSA) Plan, designed to facilitate the reimbursement process for eligible expenses incurred by employees, their spouses, or dependents. This form requires detailed information about the expenses, including provider details, dates of service, and a certification by the employee regarding the eligibility and compliance of the expenses with IRS guidelines and plan rules. For those looking to get reimbursed for their FSA expenses, filling out this form accurately and submitting it along with the necessary documentation is essential. Click the button below to start your reimbursement process.

Get Form Now Download PDF

Bswift Request For Reimbursement Form PDF Details

The Bswift Request For Reimbursement form serves as a crucial tool for employees enrolled in Flexible Spending Account Plans, allowing them to seek reimbursement for eligible healthcare and dependent care expenses. It requires detailed information such as the employer details, the last four digits of the Social Security Number, employee name, contact information, and a thorough account of the expenses for which reimbursement is sought. This includes the date of service, description of the expense, the provider, and the amount requested. The form insists on the attachment of itemized documentation or an Explanation of Benefits (EOB) to substantiate the claims, prohibiting the use of canceled checks or credit card statements as proof. Moreover, it distinguishes between healthcare and dependent care expenses, each with specific requirements for reimbursement including necessary certifications about the eligibility of the expenses and adherence to IRS guidelines. For instance, it stresses the need for a Medical Necessity Form for over-the-counter medicines as per changes effective January 1, 2011. Also, the form guides the submission process, listing the acceptable means of submitting claims and provides directions for claiming both healthcare and dependent care expenses, underscoring the non-deductibility of these expenses for tax purposes upon reimbursement. Furthermore, it mentions the conditions under which terminated employees can claim expenses and elucidates on eligible and ineligible expenses as per IRS rules, imparting clarity and compliance. In doing so, the Bswift Request For Reimbursement form plays a pivotal role in facilitating the use of Flexible Spending Accounts, ensuring employees efficiently recover outlays on qualifying health and dependent care services.

Question	Answer
Form Name	Bswift Request For Reimbursement Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	bswift form, reimbursement services bswift, bswift claims, bswift reimbursment

Form Preview Example

REQUEST FOR REIMBURSEMENT FORM – FLEXIBLE SPENDING ACCOUNT PLAN

Employer:		Last 4 Digits of SS#:

Employee Name:		Phone Number:
Employee Name:		Phone Number:

Home Address:	Check this box if this is a NEW address
Home Address:	Check this box if this is a NEW address
		Email Address:

Claim Submission Instructions: To seek reimbursement for your FSA expenses, please complete the information below for eligible expenses incurred by you, your spouse or other eligible dependents. You must provide itemized/detailed documentation of the service/purchase from the provider, your insurance Explanation of Benefits (EOB) or other third-party documentation that the expenses were incurred (canceled checks/credit card statements will not be accepted). Print or type the information requested, then sign and date the form – if the form is not signed, your claim will be returned to you for a signature. You may fax, email or mail this form along with your supporting documentation to bswift. To check your account balance online, print forms, or access a list of eligible expenses, please visit: www.hrbenefitsdirect.com/bswift

HEALTH CARE FLEXIBLE SPENDING ACCOUNT EXPENSES

*** Remember to submit a Medical Necessity Form for over-the-counter medicines due to IRS guideline changes effective January 1, 2011!***

		NAME & RELATIONSHIP OF PERSON WHO
DATE OF SERVICE	DESCRIPTION OF EXPENSE	INCURRED EXPENSE	PROVIDER OF SERVICE	* IS EXPENSE COVERED		AMOUNT OF EXPENSE
(Date services were incurred)	(Prescription, Office Visit, Dental)	(Example: Bob Jones – Spouse)	(Pharmacy, Dr. Smith, etc.)	BY ANY OTHER PLAN?		REQUESTED
				Yes	No

				Yes	No

				Yes	No

				Yes	No

				Yes	No

				Yes	No

				Yes	No

* If the expense is covered by an insurance plan, please submit the insurance EOB with this form.				TOTAL EXPENSES:		$

If you are submitting a claim for expenses incurred by a dependent and we need further information in order to process the claim, your dependent is deemed to authorize you to respond to our request.

To the best of my knowledge and belief, my statements on this Request for Reimbursement Form are complete and true. I certify that my dependent or I have received the services described above on the dates indicated. If I am enrolled in a post-deductible/limited-purpose FSA, I further certify that the expenses are qualified under the Plan, meaning that the expenses are for uninsured dental care, uninsured vision care, uninsured preventive care or uninsured expenses in excess of the minimum annual deductible under a qualified high deductible health plan and I am providing, along with this claim form, substantiation from an independent third party that the expense are qualified. If the expense is for my spouse or dependent, I certify that the person listed is my spouse or meets the definition of dependent in the Plan. I certify that I have not been reimbursed previously for these expenses under the health care FSA. I certify that these expenses have not been reimbursed by, and I will not seek reimbursement for these expenses from, any medical plan, insurance plan, health care FSA or other source. If the reimbursement is requested for prescribed drugs, I certify that such drugs are not prescribed for cosmetic purposes. If the reimbursement request is for an over-the-counter drug, I certify that the drug was prescribed by a physician or is insulin. I understand that these expenses may not be used to claim any federal income tax deduction. I authorize a deduction in my health care FSA in the amount of the reimbursement.

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT EXPENSES

DATES OF SERVICE

(‘From – Through’ Dates the Care was Provided)

DEPENDENT’S NAME

& RELATIONSHIP

**DEPENDENT CARE PROVIDER’S SIGNATURE (Only if no receipt from the provider is attached)

AMOUNT OF EXPENSE

REQUESTED

** Form must include dep. care provider’s signature above if you are not supplying a receipt with this form.

TOTAL EXPENSES:

For information as to what dependent care expenses can be reimbursed, see the summary plan description and IRS Publication 503. Note: To be reimbursed, you must provide the dependent care provider’s SIGNATURE (OR a receipt from the provider) . To the best of my knowledge and belief, my statements on this Request for Reimbursement Form are complete and true. I have read, understand and make the certifications contained in the Certificate of Qualifying Dependent Care Expenses on the reverse side of this Form. I understand that these dependent care expenses may not be used to claim any federal income tax deduction or credit (including the dependent care tax credit). I certify that I have obtained the taxpayer identification number (in the case of an entity) or Social Security number (in the case of an individual) who provides the above described care for inclusion on IRS Form 2441 which will be filed with my annual federal income tax return. I authorize a reduction in my dependent care FSA in the amount of the reimbursement.

EMPLOYEE SIGNATURE:

DATE:

The fact that complete and proper claims for benefits made by individuals covered by the Program will be promptly processed, but that in the event there are delays in processing claims, the individuals covered by the Program shall have no greater rights to interest or other remedies against TPA than as otherwise afforded them by law.

5001 Plainfield Ave NE, Ste A; Grand Rapids, MI 49525  Ph (616) or (866) 365-2413  Fx (616) 301-1873 or (888) 856-7852  FSAdept@bswift.com

rev 09/2012

ADDITIONAL INSTRUCTIONS FOR FSA CLAIMS

1.Only employees participating in the plan can submit a reimbursement form.

2.Current employees may submit claims for up to a specific number of days after the plan year-end for expenses incurred during the prior plan year or applicable grace period. Please consult your benefits dept or bswift for this information.

3.Terminated employees may be reimbursed for expenses incurred through the last day of participation (termination date). Claims must be submitted within a specific number of days after the date termination occurred. Please consult your benefits dept or bswift for this information.

4.Reimbursements may only be made for eligible expenses incurred during the plan year or applicable grace period.

5.IRS rules stipulate that any money left in your account(s) after all reimbursements for the Plan Year have been processed may not be carried forward or returned. Money left in the health care spending account may not be used to reimburse dependent care expenses, and vice versa.

6.If you receive reimbursement for expenses, you may not claim these expenses as a deduction for income tax purposes.

7.Complete the information on the reimbursement request form for each amount claimed for reimbursement.

8.Attach an itemized receipt or bill showing the date of service, amount of charge, patient name, name and address of provider and a complete description of the expense. Make a photocopy of the documentation and the reimbursement form for your records. If you have medical/Rx, dental, vision coverage for the expenses, please attach copies of Explanation of Benefits (EOBs) from your insurance carrier(s).

9.Submit your reimbursement form to bswift. A blank Request for Reimbursement Form will be sent with your reimbursement check. Additional forms are available from your Employer’s Human Resources Department or via web at: www.hrbenefitsdirect.com/bswift

ELIGIBLE HEALTH CARE EXPENSES

Following is a list of the more common eligible expenses. A comprehensive list is available online under Health Care Expense Table. Some expenses may require a medical necessity form from the treating physician. For more information, please contact your bswift representative directly.

-Acupuncture

-Bandages

-Blood-pressure Monitoring Devices

-Blood-sugar Test Kits and Test Strips

-Braces and Supports

-Catheters

-Chiropractic Care

-Contact Lenses (corrective lenses - not cosmetic),Supplies and Solution

-Co-pays and Co-insurance Amounts

-Deductibles

-Dental Cleanings, X-rays, Fillings, Braces, Extractions

-Diabetic Supplies

-Eye Exams, Eyeglasses (corrective lenses), Equipment and Materials (excluding clip-on sunglasses/non-Rx sunglasses)

-First Aid Supplies

-Flu Shots

-Hearing Aids

-Immunizations

-Incontinence Supplies

-Insulin

-Laboratory Fees

-Laser Eye Surgery/Lasik

-Mileage for Person to Receive Medical Care

-Obstetrical Expenses

-Occlusal Guards to Prevent Teeth Grinding

-Orthodontia

-Physical Exams

-Physical Therapy

-Pregnancy Tests

-Prescribed Contraceptives

-Prescription Drugs/Medicines

-Psychiatric Care

-Reading Glasses

-Smoking Cessation Programs

-Therapy (medically-related only - NOT marriage counseling, general mental health wellness, relief of stress)

-Walkers, Wheelchairs, Canes

INELIGIBLE HEALTH CARE EXPENSES

Following are examples of SOME expenses that are not eligible under the HCFSA plan. This is not a complete list. If you have specific questions, please contact your bswift representative directly.

-Amounts paid by a health insurance plan or any other plan (FSA, HRA, HSA)

-COBRA Premiums

-Cosmetic Procedures

-Diet Foods

-Expenses You Claim on Your Federal Income Tax Return

-Expenses Incurred Before you began Participating in the FSA

-Face Creams

-Feminine Hygiene Products (Tampons, etc.)

-Funeral Expenses

-Hair Removal/Transplants

-Illegal Operations and Treatments

-Insurance Premiums

-Late Fees/Missed Appointment Fees

-Makeup/Nail Polish

-Marijuana or Other Controlled Substances in Violation of Federal Law

-Maternity Clothes

-Mouthwash/Dental Floss/Toothbrush/Toothpaste

-Nursing Services for Health Baby

-One-A-Day Vitamins

-Over-the-counter Drugs Unless Prescribed by a Physician or the Drug is Insulin

-Prepayments for Services

-Safety Glasses (non-prescription)

-Shampoo/Soap/Moisturizers/Deodorant

-Shaving Cream/Lotion

-Tanning Salons/Equipment

-Teeth Whitening

-Vision Discount Program/Service Agreements/Warranties

DEPENDENT CARE FSA REQUIREMENTS

By signing and submitting the Reimbursement Request Form, you are certifying that expenses for which you request reimbursement meet ALL of the following conditions:

1.The expenses are incurred for services rendered after the date of your election to receive dependent care assistance benefits and during the plan year to which the election applies.

2.The expenses are incurred so you (and your spouse, if you are married) can work or look for work. Exception: If your spouse is not working or looking for work when the expenses are incurred, you certify that he or she is a full- time student or is physically or mentally incapable of self-care.

3.The amount of the reimbursement requested, when aggregated with all other reimbursements received by you under the Plan during the same calendar year, do not exceed the lesser of (A) your earned income; or (B) if you are married, your spouse’s actual or deemed earned income.

Please refer to IRS Publication 503 to determine the earned income amount for your spouse.

4.Each dependent for whom you incur the expenses is (A) a person under age 13 for whom you are entitled to claim a dependency exemption on your federal income tax return, or (B) your spouse or a person who is your dependent under federal tax law (even if you may not claim the dependency exemption on your federal income tax return), but only if he or she is physically or mentally incapable of self-care.

5.You (or you and your spouse together) are providing at least 50% of the cost of maintaining your household, and the expenses are incurred when at least one member of your household is a person described in 4(A) or 4(B) above.

6.The expenses are incurred for the care of a dependent, or for related incidental household services.

7.If the expenses are incurred for services outside your household, they are incurred for the care of a dependent who is described in 4(A) above

(or who is described in 4(B) above and regularly spends at least eight hours per day in your household).

8.If the expenses are incurred for services provided by a dependent care center (i.e., a facility that provides care for more than six individuals not residing at the facility), the center complies with all applicable state and local laws and regulations.

9.The person who provided care was not your spouse or a person whom you can claim as a tax dependent. If your child provided the care, he or she must be age 19 or older at the end of the year in which the expenses are incurred.

10.The expenses are not paid for services outside your household at a camp where the dependent stays overnight.

How to Edit Bswift Request For Reimbursement Form Online for Free

Working with PDF documents online is quite easy using our PDF tool. You can fill out you claim bswift here and try out many other options we offer. Our team is continuously working to enhance the editor and make it even easier for people with its many functions. Enjoy an ever-evolving experience now! To begin your journey, take these easy steps:

Step 1: First of all, access the editor by clicking the "Get Form Button" in the top section of this webpage.

Step 2: With our state-of-the-art PDF editor, you'll be able to do more than just complete forms. Edit away and make your docs look high-quality with customized textual content put in, or tweak the original content to perfection - all that comes along with an ability to add just about any photos and sign the file off.

This form will require particular information to be filled out, therefore make sure to take the time to type in what's asked:

1. Whenever completing the you claim bswift, ensure to include all of the needed blanks in the associated section. This will help facilitate the work, allowing for your details to be processed fast and appropriately.

2. Right after completing this section, head on to the subsequent step and fill out the necessary particulars in all these blank fields - DATES OF SERVICE, From Through Dates the Care was, DEPENDENTS NAME, RELATIONSHIP, DEPENDENT CARE PROVIDERS SIGNATURE, Only if no receipt from the, AMOUNT OF EXPENSE, REQUESTED, Form must include dep care, TOTAL EXPENSES , For information as to what, EMPLOYEE SIGNATURE, DATE, The fact that complete and proper, and Plainfield Ave NE Ste A Grand.

It is easy to make an error when filling out your DEPENDENT CARE PROVIDERS SIGNATURE, for that reason make sure that you look again before you submit it.

Step 3: Make sure that your information is right and click "Done" to complete the project. Join FormsPal today and easily get access to you claim bswift, ready for download. Each and every change you make is handily preserved , meaning you can edit the file at a later stage if needed. FormsPal is invested in the confidentiality of all our users; we make certain that all information put into our editor remains secure.

Bswift Request For Reimbursement Form – Fill Out and Use This PDF

Bswift Request For Reimbursement Form PDF Details

Form Preview Example

How to Edit Bswift Request For Reimbursement Form Online for Free

Bswift Request For Reimbursement Form isn’t the one you’re looking for?

Related Documents