Fbmc Claim Form PDF Details

Navigating through healthcare and benefits paperwork can be a daunting task, filled with specific instructions and requirements that must be followed to ensure a smooth process. One such form, the FBMC Claim Form, is a crucial document for individuals seeking reimbursement for Flexible Spending Accounts (FSA), Health Reimbursement Arrangements (HRA), and Payment Card transactions related to medical and dependent care expenses. This document requires meticulous attention to detail, starting with the use of black ink for completion, to ensuring that all instructions on the back are read and understood prior to filling it out. Importantly, it emphasizes the need for submitting copies of original receipts to support the claim, a step that underscores the importance of keeping personal records for verification purposes. With sections specifically designed to capture personal data, details of the service provider, types of expenses incurred, and the necessary signatures and certifications, the form acts as a comprehensive tool for managing and processing claims efficiently. By providing clear indications for new address checks, payment types, and meticulously breaking down expenses, it guides participants through the complexities of claiming reimbursements in a structured and user-friendly manner.

QuestionAnswer
Form NameFbmc Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesSSEmployeeorFBMCIDNumber, myfbmc nys, fbmc claim form, splan

Form Preview Example

PERSONAL DATA

Claim Form

USE ONLY BLACK INK

 

Page _____of _____

for FSA, HRA and the Payment Card

 

 

 

PLEASE READ THE INSTRUCTIONS ON THE BACK PRIOR TO COMPLETION.

 

KEEP A COPY OF THIS FORM FOR YOUR RECORDS. SEND COPIES OF ORIGINAL RECEIPTS.

 

 

 

ＵｈｔｌＡ＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ＃＃Ｏｖｔｌ＃ＷｏｖｕｌＡ＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ

Ｚ｛ｙｌｌ｛＃ＨｋｋｙｌｚｚＡ＃＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ Ｊｐ｛｠Ａ＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆＺ｛ｈ｛ｌＡ＃ｆｆｆｆｆｆｆ ａｐｗＡ＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ

ＺＺ＊３＃Ｌｔｗｓｖ｠ｌｌ＃ｖｙ＃ＭＩＴＪ＃ＰＫ＃Ｕ｜ｔｉｌｙＡ＃＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ＃Ｌｔｗｓｖ｠ｌｙＡ＃＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ Ｋｈ｠＃［ｐｔｌ＃ＷｏｖｕｌＡ＃＃ｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆｆ

PLEASE CHECK HERE IF THIS IS A NEW ADDRESS.

I understand, agree and certify to the following:

ﾋ＃ Ｐ＃～ｐｓｓ＃｜ｚｌ＃ｔ｠＃ＭＺＨ６ＯＹＨ＃｛ｖ＃ｖｕｓ｠＃ｗｈ｠＃ｍｖｙ＃ＰＹＺ４ｘ｜ｈｓｐￄｌｋ＃ｌ｟ｗｌｕｚｌｚ３＃ｗｌｙｔｐ｛｛ｌｋ＃｜ｕｋｌｙ＃ｔ｠＃Ｌｔｗｓｖ｠ｌｙﾻｚ＃ｗｓｈｕ／ｚ０３＃ｗｙｖ｝ｐｋｌｋ＃｛ｖ＃ｔｌ＃ｈｕｋ＃ｔ｠＃ＰＹＺ４ｌｓｐｎｐｉｓｌ＃ｋｌｗｌｕｋｌｕ｛ｚ３＃ｖｕ＃｛ｏｌ＃ｋｈ｛ｌ／ｚ０＃ｐｕｋｐｊｈ｛ｌｋ＃ｉｌｓｖ～＃ｈｚ＃ｉｌｐｕｎ＃

ｐｕｊ｜ｙｙｌｋ＃～ｐ｛ｏｐｕ＃ｔ｠＃ｗｌｙｐｖｋ＃ｖｍ＃ｊｖ｝ｌｙｈｎｌ＃｜ｕｋｌｙ＃｛ｏｌ＃ｈｗｗｓｐｊｈｉｓｌ＃ｗｓｈｕ＃｠ｌｈｙ５ ﾋ＃ Ｐ＃～ｐｓｓ＃ｙｌｘ｜ｌｚ｛＃ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃ｖｕｓ｠＃ｈｍ｛ｌｙ＃｛ｏｌ＃ｚｌｙ｝ｐｊｌｚ＃ｏｈ｝ｌ＃ｉｌｌｕ＃ｗｙｖ｝ｐｋｌｋ５

ﾋ＃ Ｐ＃ｏｈ｝ｌ＃ｕｖ｛＃ｈｕｋ＃～ｐｓｓ＃ｕｖ｛＃ｚｌｌｒ＃ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃｛ｏｙｖ｜ｎｏ＃ｈｕ｠＃ｖ｛ｏｌｙ＃ｚｖ｜ｙｊｌ３＃ｈｕｋ＃～ｐｓｓ＃ｌ｟ｏｈ｜ｚ｛＃ｈｓｓ＃｛ｏｌ＃ｖ｛ｏｌｙ＃ｚｖ｜ｙｊｌｚ＃ｖｍ＃ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛３＃ｐｕｊｓ｜ｋｐｕｎ＃｛ｏｖｚｌ＃ｗｙｖ｝ｐｋｌｋ＃｜ｕｋｌｙ＃ｔ｠＃Ｌｔｗｓｖ｠ｌｙﾻｚ＃ｗｓｈｕ／ｚ０３＃ｉｌｍｖｙｌ＃ｚｌｌｒｐｕｎ＃

ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃ｍｙｖｔ＃ｔ｠＃ＭＺＨ＃ｖｙ＃ＯＹＨ５

ﾋ＃ Ｐ＃ｚｗｌｊｐￄｊｈｓｓ｠＃ｙｌｓｌｈｚｌ＃ｔ｠＃Ｌｔｗｓｖ｠ｌｙ＃ｈｕｋ＃ＭＩＴＪ＃ｍｙｖｔ＃ｈｕ｠＃ｓｐｈｉｐｓｐ｛｠＃ｙｌｚ｜ｓ｛ｐｕｎ＃ｍｙｖｔ＃ｌｐ｛ｏｌｙ＃ｔ｠＃ｗｈｙ｛ｐｊｐｗｈ｛ｐｖｕ＃ｐｕ＃ｈｕ｠＃ＭＺＨ６ＯＹＨ＃ｖｙ＃ｍｖｙ＃ｈｕ｠＃ｔｐｚｙｌｗｙｌｚｌｕ｛ｈ｛ｐｖｕ＃Ｐ＃ｔｈｒｌ＃ｙｌｎｈｙｋｐｕｎ＃ｔ｠＃ｙｌｘ｜ｌｚ｛ｚ＃ｍｖｙ＃ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛５ ﾋ＃ Ｐ＃ｏｈ｝ｌ＃ｙｌｈｋ＃ｈｕｋ＃｜ｕｋｌｙｚ｛ｈｕｋ＃｛ｏｌ＃ｐｕｍｖｙｔｈ｛ｐｖｕ＃ｖｕ＃｛ｏｌ＃ｍｙｖｕ｛＃ｈｕｋ＃ｉｈｊｒ＃ｖｍ＃｛ｏｐｚ＃ｍｖｙｔ５

ﾋ＃ Ｐｍ＃Ｐ＃ｗｈｙ｛ｐｊｐｗｈ｛ｌ＃ｐｕ＃ｔ｠＃Ｌｔｗｓｖ｠ｌｙﾻｚ＃Ｋｌｗｌｕｋｌｕ｛＃Ｊｈｙｌ＃ＭＺＨ＃Ｗｓｈｕ３＃Ｐ＃～ｐｓｓ＃ￄｓｌ＃ｈ＃Ｍｖｙｔ＃９；；８＃～ｐ｛ｏ＃ｔ｠＃ｐｕｊｖｔｌ＃｛ｈ｟＃ｙｌ｛｜ｙｕ＃ｈｕｋ＃ｗｙｖ｝ｐｋｌ＃ｈｕ｠＃｛ｈ｟ｗｈ｠ｌｙ＃ｐｋｌｕ｛ｐￄｊｈ｛ｐｖｕ＃ｕ｜ｔｉｌｙ＃ｙｌｘ｜ｐｙｌｋ５ ﾋ＃ ［ｏｌ＃ｋｌｗｌｕｋｌｕ｛＃ｊｈｙｌ＃ｌ｟ｗｌｕｚｌｚ＃Ｐ＃ｚ｜ｉｔｐ｛＃ｍｖｙ＃ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃～ｌｙｌ＃ｐｕｊ｜ｙｙｌｋ＃｛ｖ＃ｈｓｓｖ～＃ｔｌ＃ｈｕｋ＃ｔ｠＃ｚｗｖ｜ｚｌ＃／ｐｍ＃ｔｈｙｙｐｌｋ０＃｛ｖ＃～ｖｙｒ＃ｖｙ＃ｈｊ｛ｐ｝ｌｓ｠＃ｓｖｖｒ＃ｍｖｙ＃～ｖｙｒ５

Participant’s Signature: ____________________________________________________________ Date: __________________

(Required to process claim/reimbursement)

PAYMENT TYPE Place a check mark []＃ｐｕ＃｛ｏｌ＃ｉｖ｟／ｌｚ０＃ｈｕｋ＃ￄｓｓ＃ｐｕ＃ｊｓｈｐｔ＃ｈｔｖ｜ｕ｛＃ｖｍ＃ｈｕ｠＃｛ｏｈ｛＃ｈｗｗｓ｠＃ｉｌｓｖ～＃／MEDICAL FSA or HRA expenses ONLY):

A. ＋ｆｆｆｆｆｆｆｆｆｆｆｆｆｆ＃＃Ｐ＃｜ｚｌｋ＃｛ｏｌ ｊｈｙｋ＃｛ｖ＃ｗｈ｠＃ｍｖｙ＃｛ｏｌｚｌ＃ｌ｟ｗｌｕｚｌｚ＃４＃ｔ｜ｚ｛＃ｈ｛｛ｈｊｏ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｍｖｙ＃｛ｙｈｕｚｈｊ｛ｐｖｕｚ＃ｙｌｘ｜ｐｙｐｕｎ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃５†

B. ＋ｆｆｆｆｆｆｆｆｆｆｆｆｆｆ＃＃Ｗｓｌｈｚｌ＃ｗｈ｠＃ｔｌ＃ｍｖｙ＃｛ｏｌｚｌ＃ｖ｜｛４ｖｍ４ｗｖｊｒｌ｛＃ｌ｟ｗｌｕｚｌｚ＃４＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｔ｜ｚ｛＃ｉｌ＃ｈ｛｛ｈｊｏｌｋ５†

C.

 

＋ｆｆｆｆｆｆｆｆｆｆｆｆｆｆ＃＃Ｗｓｌｈｚｌ＃ｈｗｗｓ｠＃ｈ｛｛ｈｊｏｌｋ＃ｋｖｊ｜ｔｌｕ｛ｚ＃ｈｚ＃ｚ｜ｉｚ｛ｐ｛｜｛ｐｖｕ＃｛ｖ～ｈｙｋ＃ｊｈｙｋ＃｛ｙｈｕｚｈｊ｛ｐｖｕｚ＃ｙｌｘ｜ｐｙｐｕｎ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ５＃Ｍｖｙ＃ｓｖｚ｛＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｖｙ＃＃＃

 

 

＃

ｚ｜ｉｚ｛ｈｕ｛ｐｈ｛ｐｖｕ＃ｖｍ＃ｈｕ＃ｐｕｌｓｐｎｐｉｓｌ＃ｊｏｈｙｎｌ＃†

MEDICAL FSA OR HRA Fill out completely ／｜ｚｌ＃ｍｖｙ＃ｌｓｐｎｐｉｓｌ＃ｔｌｋｐｊｈｓ＃ｌ｟ｗｌｕｚｌｚ＃ｍｖｙ＃｠ｖ｜ｙｚｌｓｍ＃ｈｕｋ＃ｘ｜ｈｓｐｍ｠ｐｕｎ＃ｋｌｗｌｕｋｌｕ｛ｚ０

 

 

CHECK (

)

 

 

 

SERVICE DATE:**

AMOUNT

 

PAYMENT TYPE

 

 

 

 

 

 

 

 

 

THAT IS YOUR

 

 

 

 

 

 

 

 

.

Name of Person

Relationship

Provider of Services*

 

 

RESPONSIBILITY

 

Card

 

 

me

 

.docs

Receiving Service

to Employee

FROM:

TO:

 

 

 

 

 

 

 

.

 

 

Pay

 

 

Sub

 

 

 

 

 

 

A

 

 

. .

 

 

 

 

 

 

 

 

 

 

B

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL THIS PAGE

$

 

 

 

 

 

 

 

 

 

 

 

 

GRAND TOTAL FOR

$

 

 

 

 

 

 

 

 

 

 

 

 

 

MULTIPLE PAGES

 

DEPENDENT CARE FSA Fill out completely ／｜ｚｌ＃ｍｖｙ＃ｊｏｐｓｋｊｈｙｌ３＃ｋｌｗｌｕｋｌｕ｛＃ｊｈｙｌ＃ｈｕｋ＃ｌｓｋｌｙ＃ｊｈｙｌ＃ｚｌｙ｝ｐｊｌｚ０

 

 

 

 

 

 

 

 

 

Name of Person

Relationship

Age and

Name and Address of Persons

SERVICE DATE:**

AMOUNT OF

 

 

 

 

 

 

 

 

REIMBURSEMENT

 

 

 

 

 

Receiving Service

to Employee

Grade

or Facility Providing Service

FROM:

TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

$

SIGNATURE OF DAY CARE PROVIDER (LISTED ABOVE)

TOTAL THIS PAGE

$

OR ATTACH STATEMENT / BILL : ________________________________________________________________________________

GRAND TOTAL

$

†＃ Ｗｓｌｈｚｌ＃ｙｌｔｌｔｉｌｙ＃｛ｖ＃ｒｌｌｗ＃ｊｖｗｐｌｚ＃ｍｖｙ＃｠ｖ｜ｙ＃ｙｌｊｖｙｋｚ５

FOR MULTIPLE

PAGES

 

１＃＃ ﾸＷｙｖ｝ｐｋｌｙ＃ｖｍ＃Ｚｌｙ｝ｐｊｌｚﾹ＃ｔｌｈｕｚ＃ｏｖｚｗｐ｛ｈｓ３＃ｋｖｊ｛ｖｙ３＃ｋｌｕ｛ｐｚ｛３＃ｋｙ｜ｎｚ｛ｖｙｌ３＃ｔｌｋｐｊｈｓ＃ｚ｜ｗｗｓ｠＃ｚ｛ｖｙｌ３＃ｌ｛ｊ５

 

 

 

 

１１＃＃ﾸＺｌｙ｝ｐｊｌ＃ｋｈ｛ｌﾹ＃ｙｌｍｌｙｚ＃｛ｖ＃ｋｈ｛ｌｚ＃ｚｌｙ｝ｐｊｌ＃～ｈｚ＃ＷＹＶ］ＰＫＬＫ＃ｖｙ＃ｈ｝ｈｐｓｈｉｓｌ＃ｍｖｙ＃ｗｐｊｒ｜ｗ３＃ｕｖ｛＃｛ｏｌ＃ｋｈ｛ｌ＃｠ｖ｜＃ｗｈｐｋ＃ｖｙ＃～ｌｙｌ＃ｊｏｈｙｎｌｋ＃ｍｖｙ＃ｐ｛５

 

 

FBMC

Ｔｈｐｓ＃｛ｖＡ＃Ｗ５Ｖ５＃Ｉｖ｟＃８？７７３＃［ｈｓｓｈｏｈｚｚｌｌ３＃Ｍｓｖｙｐｋｈ＃：９：７９４８？７７ ［ｖｓｓ４Ｍｙｌｌ＃Ｍｈ｟＃｛ｖＡ＃1-866-923-6318

Ｊ｜ｚ｛ｖｔｌｙ＃Ｚｌｙ｝ｐｊｌＡ＃８４？７７４：；９４？７８＞＃＃Ｐｕ｛ｌｙｈｊ｛ｐ｝ｌ＃Ｉｌｕｌￄ｛ｚ＃Ｐｕｍｖｙｔｈ｛ｐｖｕ＃ＳｐｕｌＡ＃８４？７７４？＝＜４：９＝９

FBMC/CLAIM_PRM_6318/0408

IMPORTANT INFORMATION FOR REIMBURSEMENT

(TO AVOID DELAYS, PLEASE READ THESE INSTRUCTIONS CAREFULLY.)

IMPORTANT REQUIREMENTS & INFORMATION ／ｕｖ｛＃ｍｖｓｓｖ～ｐｕｎ＃｛ｏｌｚｌ＃ｙｌｘ｜ｐｙｌｔｌｕ｛ｚ＃ｔｈ｠＃ｊｈ｜ｚｌ＃｠ｖ｜ｙ＃ｊｓｈｐｔ＃｛ｖ＃ｉｌ＃ｙｌｑｌｊ｛ｌｋ０ ﾋ＃ Ｊｖｔｗｓｌ｛ｌ＃ｈｓｓ＃ｓｐｕｌｚ＃ｐｕ＃｛ｏｌ＃Ｗｌｙｚｖｕｈｓ＃Ｋｈ｛ｈ＃Ｚｌｊ｛ｐｖｕ５

ﾋ＃ ＼ｚｌ＃ｉｓｈｊｒ＃ｐｕｒ＃ｖｕｓ｠５

ﾋ＃ Ｋｖ＃ｕｖ｛＃｜ｚｌ＃ｏｐｎｏｓｐｎｏ｛＃ｔｈｙｒｌｙｚ＃ｖｕ＃｠ｖ｜ｙ＃ｊｓｈｐｔ＃ｍｖｙｔ＃ｖｙ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃／～ｌ＃ｚｊｈｕ＃ｈｓｓ＃ｋｖｊ｜ｔｌｕ｛ｚ０５ ﾋ＃＃｀ｖ｜ｙ＃ＭＩＴＪ＃ＰＫ＃＊＃ｊｈｕ＃ｉｌ＃ｖｉ｛ｈｐｕｌｋ＃ｖｕ＃ｖ｜ｙ＃～ｌｉ＃ｚｐ｛ｌ＃ｈ｛＃www.myFBMC.com＃ｈｍ｛ｌｙ＃ｓｖｎｐｕ５＃

ﾋ＃ Ｚ｜ｉｔｐ｛＃ｊｖｗｐｌｚ＃ｖｍ＃ｐｕ｝ｖｐｊｌｚ３＃ｚ｛ｈ｛ｌｔｌｕ｛ｚ３＃ｉｐｓｓｚ３＃ｙｌｊｌｐｗ｛ｚ３＃ｖｙ＃ＬＶＩ＃ｐｕ＃｛ｏｌ＃ｚｈｔｌ＃ｖｙｋｌｙ＃ｈｚ＃ｓｐｚ｛ｌｋ＃ｖｕ＃｛ｏｌ＃ｊｓｈｐｔ＃ｍｖｙｔ５＃ ﾋ＃ Ｊｙｌｋｐ｛＃ｊｈｙｋ＃ｙｌｊｌｐｗ｛ｚ＃ｈｕｋ＃ｊｈｕｊｌｓｌｋ＃ｊｏｌｊｒｚ＃ｊｈｕｕｖ｛＃ｉｌ＃｜ｚｌｋ＃｛ｖ＃ｈｗｗｙｖ｝ｌ＃｠ｖ｜ｙ＃ｊｓｈｐｔ５

ﾋ＃ Ｈｊｊｖ｜ｕ｛＃ｏｖｓｋｌｙ＃ｔ｜ｚ｛＃ｚｐｎｕ＃ｈｕｋ＃ｋｈ｛ｌ＃｛ｏｌ＃ｊｓｈｐｔ＃ｍｖｙｔ５ ﾋ＃ Ｔｖｙｌ＃ｍｖｙｔｚ＃ｈｙｌ＃ｈ｝ｈｐｓｈｉｓｌ＃ｈ｛＃www.myFBMC.com５ ﾋ＃ Ｈ｛｛ｈｊｏ＃ｈｋｋｐ｛ｐｖｕｈｓ＃ｚｏｌｌ｛＃ｍｖｙ＃ｔｖｙｌ＃ｐ｛ｌｔｚ６ｓｐｕｌｚ５

ﾋ＃ Ｙｌ｛ｈｐｕ＃ｈ＃ｊｖｗ｠＃ｖｍ＃｠ｖ｜ｙ＃ｊｓｈｐｔ＃ｍｖｙｔ／ｚ０＃ｈｕｋ＃ｈｓｓ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｍｖｙ＃｠ｖ｜ｙ＃ｙｌｊｖｙｋｚ５

DOCUMENTATION REQUIREMENTS:

Medical Flexible Spending Account (MFSA) or Health Reimbursement Arrangement (HRA)＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｔ｜ｚ｛＃ｐｕｊｓ｜ｋｌ＃｛ｏｌ＃ｍｖｓｓｖ～ｐｕｎＡ ﾋ＃ Ｋｈ｛ｌ＃ｚｌｙ｝ｐｊｌ／ｚ０＃～ｌｙｌ＃ｙｌｊｌｐ｝ｌｋ＃／ｕｖ｛＃ｕｌｊｌｚｚｈｙｐｓ｠＃ｚｈｔｌ＃ｈｚ＃ｋｈ｛ｌ＃ｗｈｐｋ０

ﾋ＃ ｀ｖ｜ｙ＃ｊｖｚ｛＃ｍｖｙ＃｛ｏｌ＃ｚｌｙ｝ｐｊｌ／ｚ０５＃［ｖ｛ｈｓ＃ｈｔｖ｜ｕ｛＃｛ｏｈ｛＃ｐｚ＃｠ｖ｜ｙ＃ｙｌｚｗｖｕｚｐｉｐｓｐ｛｠５

ﾋ＃ ［｠ｗｌ＃ｖｍ＃Ｚｌｙ｝ｐｊｌ／ｚ０＃／｟４ｙｈ｠３＃ｖｍￄｊｌ＃｝ｐｚｐ｛３＃ｗｙｌｚｊｙｐｗ｛ｐｖｕ＃ｋｙ｜ｎ＃ｕｈｔｌ＃ｖｙ＃ｖ｝ｌｙ４｛ｏｌ４ｊｖ｜ｕ｛ｌｙ＃ｐ｛ｌｔ＃ｌ｛ｊ５０

ﾋ＃ Ｕｈｔｌ＃ｖｍ＃ｗｌｙｚｖｕ＃ｙｌｊｌｐ｝ｐｕｎ＃ｚｌｙ｝ｐｊｌｚ＃／｛ｏｐｚ＃ｔ｜ｚ｛＃ｉｌ＃｛ｏｌ＃ｈｊｊｖ｜ｕ｛＃ｏｖｓｋｌｙ３＃ｚｗｖ｜ｚｌ３＃ｖｙ＃ＰＹＺ＃ｌｓｐｎｐｉｓｌ＃ｋｌｗｌｕｋｌｕ｛０５ ﾋ＃ Ｈｕ＃ＬＶＩ＃ｊｈｕ＃ｉｌ＃ｚ｜ｉｔｐ｛｛ｌｋ＃ｍｖｙ＃ｐｕ＃ｓｐｌ｜＃ｖｍ＃ｈ＃ｚ｛ｈ｛ｌｔｌｕ｛＃ｖｙ＃ｉｐｓｓ５

ﾋ＃ ＯＹＨｚ＃４＃｠ｖ｜＃ｔ｜ｚ｛＃ｚ｜ｉｔｐ｛＃ｈｕ＃ＬＶＩ＃ｍｖｙ＃ｈｕ｠＃ｔｌｋｐｊｈｓ＃ｚｌｙ｝ｐｊｌｚ＃ｙｌｊｌｐ｝ｌｋ５＃Ｚｌｌ＃ｌｕｙｖｓｓｔｌｕ｛＃ｎ｜ｐｋｌ＃ｍｖｙ＃ｈｕ｠＃ｈｋｋｐ｛ｐｖｕｈｓ＃ￄｓｐｕｎ＃ｙｌｘ｜ｐｙｌｔｌｕ｛ｚ５

Orthodontics – ［ｏｌ＃ｍｖｓｓｖ～ｐｕｎ＃ｐｚ＃ｙｌｘ｜ｐｙｌｋＡ

ﾋ＃ Ｈ＃～ｙｐ｛｛ｌｕ＃ｚ｛ｈ｛ｌｔｌｕ｛＃ｍｙｖｔ＃｛ｏｌ＃｛ｙｌｈ｛ｐｕｎ＃ｋｌｕ｛ｐｚ｛６ｖｙ｛ｏｖｋｖｕ｛ｐｚ｛＃ｚｏｖ～ｐｕｎ＃｛ｏｌ＃｛｠ｗｌ＃ｈｕｋ＃ｋｈ｛ｌ＃｛ｏｌ＃ｚｌｙ｝ｐｊｌ＃ｐｕｊ｜ｙｙｌｋ３＃｛ｏｌ＃ｕｈｔｌ＃ｖｍ＃｛ｏｌ＃ｌｓｐｎｐｉｓｌ＃

ｐｕｋｐ｝ｐｋ｜ｈｓ＃ｙｌｊｌｐ｝ｐｕｎ＃｛ｏｌ＃ｚｌｙ｝ｐｊｌ＃ｈｕｋ＃｛ｏｌ＃ｊｖｚ｛＃ｍｖｙ＃｛ｏｌ＃ｚｌｙ｝ｐｊｌ＃ｈｕｋ

ﾋ＃ Ｈ＃ｊｖｗ｠＃ｖｍ＃｛ｏｌ＃ｗｈ｛ｐｌｕ｛ﾻｚ＃ｊｖｕ｛ｙｈｊ｛＃～ｐ｛ｏ＃｛ｏｌ＃ｋｌｕ｛ｐｚ｛６ｖｙ｛ｏｖｋｖｕ｛ｐｚ｛＃ｍｖｙ＃｛ｏｌ＃ｖｙ｛ｏｖｋｖｕ｛ｐｈ＃｛ｙｌｈ｛ｔｌｕ｛＃／ｖｕｓ｠＃ｙｌｘ｜ｐｙｌｋ＃ｐｍ＃ｈ＃ｗｈｙ｛ｐｊｐｗｈｕ｛＃ｙｌｘ｜ｌｚ｛ｚ＃

ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃ｍｖｙ＃｛ｏｌ＃｛ｖ｛ｈｓ＃ｗｙｖｎｙｈｔ＃ｊｖｚ｛＃ｚｗｙｌｈｋ＃ｖ｝ｌｙ＃ｈ＃ｗｌｙｐｖｋ＃ｖｍ＃｛ｐｔｌ０５＃ Note:＃Ｙｌｐｔｉ｜ｙｚｌｔｌｕ｛＃ｖｍ＃｛ｏｌ＃ｍ｜ｓｓ＃ｖｙ＃ｐｕｐ｛ｐｈｓ＃ｗｈ｠ｔｌｕ｛＃ｈｔｖ｜ｕ｛＃ｔｈ｠＃ｖｕｓ｠＃ｖｊｊ｜ｙ＃ｋ｜ｙｐｕｎ＃｛ｏｌ＃ｗｓｈｕ＃｠ｌｈｙ＃ｐｕ＃～ｏｐｊｏ＃｛ｏｌ＃ｉｙｈｊｌｚ＃ｈｙｌ＃ￄｙｚ｛＃ｐｕｚ｛ｈｓｓｌｋ５＃

Dependent Care Flexible Spending Account (DCFSA)

ﾋ＃ Ｐｍ＃｛ｏｌ＃ｗｌｙｚｖｕｈｓ＃ｋｈ｛ｈ＃ｚｌｊ｛ｐｖｕ＃ｈｕｋ＃｛ｏｌ＃ｋｌｗｌｕｋｌｕ｛＃ｊｈｙｌ＃ｚｌｊ｛ｐｖｕ＃ｈｙｌ＃ｊｖｔｗｓｌ｛ｌｋ＃ｐｕ＃｛ｏｌｐｙ＃ｌｕ｛ｐｙｌ｛｠＃ｈｕｋ＃｛ｏｌ＃ｍｖｙｔ＃ｏｈｚ＃ｉｌｌｕ＃ｚｐｎｕｌｋ＃ｉ｠＃｠ｖ｜ｙｚｌｓｍ＃ｈｕｋ＃

｠ｖ｜ｙ＃ｋｈ｠＃ｊｈｙｌ３＃ｕｖ＃ｍ｜ｙ｛ｏｌｙ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｐｚ＃ｕｌｌｋｌｋ５

ﾋ＃ Ｐｕ＃ｓｐｌ｜＃ｖｍ＃｛ｏｌ＃ｗｙｖ｝ｐｋｌｙ＃ｚｐｎｕｈ｛｜ｙｌ３＃｠ｖ｜＃ｊｈｕ＃ｚ｜ｉｔｐ｛＃ｈ＃ｚ｛ｈ｛ｌｔｌｕ｛３＃ｐｕ｝ｖｐｊｌ＃ｖｙ＃ｉｐｓｓ＃｛ｏｈ｛＃ｚｏｖ～ｚ＃｛ｏｌ＃ｕｈｔｌ＃ｈｕｋ＃ｈｋｋｙｌｚｚ＃ｖｍ＃｛ｏｌ＃ｗｙｖ｝ｐｋｌｙ３＃ｉｌｎｐｕｕｐｕｎ＃

ｈｕｋ＃ｌｕｋｐｕｎ＃ｋｈ｛ｌｚ＃ｖｍ＃｛ｏｌ＃ｗｙｖ｝ｐｋｌｋ＃ｚｌｙ｝ｐｊｌｚ３＃｛ｏｌ＃ｊｖｚ｛＃ｖｍ＃ｚｌｙ｝ｐｊｌ／ｚ０３＃ｈｕｋ＃｛ｏｌ＃ｕｈｔｌ＃ｖｍ＃｛ｏｌ＃ｌｓｐｎｐｉｓｌ＃ｋｌｗｌｕｋｌｕ｛／ｚ０５

ﾋ＃ Ｊｓｈｐｔ＃ｙｌｘ｜ｌｚ｛ｚ＃ｍｖｙ＃ｔ｜ｓ｛ｐｗｓｌ＃ｔｖｕ｛ｏｚ＃～ｐｓｓ＃ｉｌ＃ｗｙｖｙｈ｛ｌｋ＃ｈｕｋ＃ｐ｛ｌｔｐ｡ｌｋ＃ｉｈｚｌｋ＃ｖｕ＃｛ｏｌ＃ｕ｜ｔｉｌｙ＃ｖｍ＃ｔｖｕ｛ｏｚ＃ｓｐｚ｛ｌｋ５＃Ｗｈ｠ｔｌｕ｛＃～ｐｓｓ＃ｉｌ＃ｐｚｚ｜ｌｋ＃ｈｍ｛ｌｙ＃｛ｏｌ＃

ｌｕｋ＃ｖｍ＃ｌｈｊｏ＃ｔｖｕ｛ｏ＃ｍｖｙ＃～ｏｐｊｏ＃ｚｌｙ｝ｐｊｌｚ＃～ｌｙｌ＃ｐｕｊ｜ｙｙｌｋ３＃ｉｈｚｌｋ＃ｖｕ＃｛ｏｌ＃ｈ｝ｈｐｓｈｉｓｌ＃ｉｈｓｈｕｊｌ＃ｐｕ＃｠ｖ｜ｙ＃ｈｊｊｖ｜ｕ｛５

ﾋ＃ Ｌｋ｜ｊｈ｛ｐｖｕｈｓ＃ｌ｟ｗｌｕｚｌｚ＃ｐｕｊ｜ｙｙｌｋ＃ｍｖｙ＃ｈ＃ｊｏｐｓｋ＃ｐｕ＃ｒｐｕｋｌｙｎｈｙ｛ｌｕ＃ｈｕｋ＃｜ｗ＃ｈｙｌ＃ｕｖ｛＃ｙｌｐｔｉ｜ｙｚｈｉｓｌ５＃［ｏｌ＃ｊｖｚ｛＃ｖｍ＃ｋｌｗｌｕｋｌｕ｛＃ｊｈｙｌ＃ｉｌｍｖｙｌ＃ｈｕｋ＃ｈｍ｛ｌｙ＃ｚｊｏｖｖｓ＃

ｐｚ＃ｙｌｐｔｉ｜ｙｚｈｉｓｌ５

ﾋ＃ Ｌ｟ｗｌｕｚｌｚ＃ｚ｜ｊｏ＃ｈｚ＃｛｜ｐ｛ｐｖｕ３＃ｙｌｎｐｚ｛ｙｈ｛ｐｖｕ＃ｍｌｌｚ３＃ｈｊ｛ｐ｝ｐ｛｠＃ｍｌｌｚ３＃ｉｖｖｒｚ３＃ｚ｜ｗｗｓｐｌｚ＃ｈｕｋ＃ｔｌｈｓｚ＃ｈｙｌ＃ｕｖ｛＃ｙｌｐｔｉ｜ｙｚｈｉｓｌ５

Special Requirements – Ｐｕ＃ｈｋｋｐ｛ｐｖｕ＃｛ｖ＃｛ｏｌ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｕｖ｛ｌｋ＃ｈｉｖ｝ｌ３＃ｚｖｔｌ＃ｚｌｙ｝ｐｊｌｚ＃ｙｌｘ｜ｐｙｌ＃ｈｋｋｐ｛ｐｖｕｈｓ＃ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｚ｜ｊｏ＃ｈｚ＃ｈ＃Ｓｌ｛｛ｌｙ＃ｖｍ＃ Ｔｌｋｐｊｈｓ＃Ｕｌｌｋ３＃ｈ＃Ｊｈｗｐ｛ｈｓ＃Ｌ｟ｗｌｕｚｌ＃＾ｖｙｒｚｏｌｌ｛３＃ｖｙ＃ｈ＃Ｗｌｙｚｖｕｈｓ＃＼ｚｌ＃Ｚ｛ｈ｛ｌｔｌｕ｛５＃Ｗｓｌｈｚｌ＃｝ｐｚｐ｛＃www.myFBMC.com ｍｖｙ＃ｊｖｗｐｌｚ＃ｈｕｋ＃ｋｌｚｊｙｐｗ｛ｐｖｕ＃ｖｍ＃｜ｚｌ５

Toll-Free Fax to: 1-866-923-6318

Mail to:＃Ｍｙｐｕｎｌ＃Ｉｌｕｌￄ｛ｚ＃Ｔｈｕｈｎｌｔｌｕ｛＃Ｊｖｔｗｈｕ｠＃／ＭＩＴＪ０３＃Ｗ５Ｖ５＃Ｉｖ｟＃８？７７３＃［ｈｓｓｈｏｈｚｚｌｌ３＃ＭＳ＃：９：７９４８？７７

Ｐｕ｛ｌｙｈｊ｛ｐ｝ｌ＃Ｉｌｕｌￄ｛ｚ＃Ｐｕｍｖｙｔｈ｛ｐｖｕ＃ＳｐｕｌＡ＃８４？７７４？＝＜４：９＝９

］ｐｚｐ｛＃www.myFBMC.com＃ｍｖｙ＃ｍｙｌｘ｜ｌｕ｛ｓ｠＃ｈｚｒｌｋ＃ｘ｜ｌｚ｛ｐｖｕｚ３＃ｈｊｊｖ｜ｕ｛＃ｉｈｓｈｕｊｌｚ３＃ ｋｖｊ｜ｔｌｕ｛ｈ｛ｐｖｕ＃ｙｌｘ｜ｐｙｌｔｌｕ｛ｚ＃ｍｖｙ＃ｊｈｙｋ＃｛ｙｈｕｚｈｊ｛ｐｖｕｚ３＃ｈｕｋ＃ｍｖｙｔｚ５

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How one can fill in FBMC stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - PAYMENT TYPE Place a check mark, I used the payment card to pay for, Please apply attached documents as, MEDICAL FSA OR HRA Fill out, CHECK, PAYMENT TYPE, A Card, C Sub docs B Pay me, Name of Person Receiving Service, Relationship to Employee, Provider of Services, SERVICE DATE, FROM, AMOUNT THAT IS YOUR RESPONSIBILITY, and DEPENDENT CARE FSA Fill out with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in segment 2 of FBMC

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