Fsafeds Claim Form PDF Details

The Fsafeds Claim Form is a document that reports an employee's injury and requests benefits from the workers' compensation program. The form must be completed and filed with the state when an injury occurs. Benefits may include medical expenses, income replacement, and death benefits. Workers' compensation is a mandatory insurance program that provides benefits to employees who are injured or become ill as a result of their job. It is designed to protect employers from lawsuits and employees from lost wages. To find out more about how workers' compensation can help you, contact an attorney today.

QuestionAnswer
Form NameFsafeds Claim Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesfsafeds health claim, fsafeds health care claim form, fsafeds health online, fsafeds claim form

Form Preview Example

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 www.FSAFEDS.com. 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:

ｳ฀฀Ａｌｌｏｗａｂｌｅ฀ｅｘｐｅｎｓｅｓ฀ｃｏｖｅｒｅｄ，฀ｂｕｔ฀ｎｏｔ฀ｆｕｌｌｙ฀ｒｅｉｍｂｕｒｓｅｄ，฀ｂｙ฀ａｎｙ฀ｂｅｎｅｬｔ฀ｐｌａｎｓ．฀฀Ａｔｔａｃｈ฀ａ฀ｃｏｐｙ฀ｏｆ฀ｔｈｅ฀ｐｌａｎ＇ｓ฀Ｅｘｐｌａｎａｔｉｏｎ฀ｏｆ฀Ｂｅｎｅｬｔｓ฀Ｓｔａｔｅｍｅｎｔ฀（ＥＯＢ）฀

ｏｒ฀ｉｔｅｍｉｚｅｄ฀ｒｅｃｅｉｐｔ฀ｆｒｏｍ฀ｙｏｕｒ฀ｐｒｏｖｉｄｅｒ．฀

ｳ฀฀Ａｌｌｏｗａｂｌｅ฀ｅｘｐｅｎｓｅｓ฀ｎｏｔ฀ｃｏｖｅｒｅｄ฀ｂｙ฀ａｎｙ฀ｂｅｎｅｬｔ฀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

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

Ａ฀

Ｂ฀

Ｃ฀

Ｄ฀

 

１฀

２฀

３฀

４

YESNO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Section 1: Complete all areas of “Employee Information.” You may use your User ID instead of your SSN in part 1 of the claim form. You will receive an email confirming receipt of your claim.

For Sections 2 & 5: Fill in your expense – you can use one line to show a total of multiple expenses within the same Coverage Code. However, the expenses will be processed separately, and will be reflected as separate amounts on your account.

฀ｳ฀฀Ｃｏｍｐｌｅｔｅ฀ａｌｌ฀ｓｅｃｔｉｏｎｓ฀ｏｆ฀ｔｈｅ฀ｆｏｒｍ．฀Ｓｉｇｎ฀ａｎｄ฀ｄａｔｅ฀ｔｈｅ฀ｂｏｔｔｏｍ฀ｏｆ฀ｔｈｅ฀ｆｏｒｍ．

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

Step 2: Attach supporting documentation. Please refer to the Clean Claim Quick Reference Guide for details.

In addition to completing the form, you must submit the documentation described under EITHER A OR B below:

A. Explanation of Benefits Form (EOB): This is the form you typically 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 EOB will show the amount of expenses paid by the plan and the amount you must pay. For expenses

ｔｈａｔ฀ａｒｅ฀ｐａｒｔｉａｌｌｙ฀ｃｏｖｅｒｅｄ฀ｂｙ฀ｙｏｕｒ，฀ｏｒ฀ｙｏｕｒ฀ｄｅｐｅｎｄｅｎｔ＇ｓ，฀ｏｒ฀ｙｏｕｒ฀ｔｈｒｏｕｇｈ฀ａｇｅ฀２６฀ａｄｕｌｔ฀ｃｈｉｌｄ＇ｓ฀ｍｅｄｉｃａｌ，฀ｄｅｎｔａｌ฀ or vision plan(s), you must attach the EOB.

B. All Other Expenses:฀฀Ｆｏｒ฀ｅｘｐｅｎｓｅｓ฀ｎｏｔ฀ｃｏｖｅｒｅｄ฀ａｔ฀ａｌｌ฀ｂｙ฀ｙｏｕｒ，฀ｏｒ฀ｙｏｕｒ฀ｄｅｐｅｎｄｅｎｔ＇ｓ，฀ｏｒ฀ｙｏｕｒ฀ｔｈｒｏｕｇｈ฀ａｇｅ฀２６฀ adult child’s medical, dental or vision plan(s), or when you do not receive an EOB, your claim must include acceptable evidence of your expenses. A cancelled check is not considered acceptable evidence. Acceptable evidence includes receipts which contain the following information:

฀฀ ｳ฀฀Ｔｙｐｅ฀ｏｆ฀ｓｅｒｖｉｃｅ฀ｏｒ฀ｐｒｏｄｕｃｔ฀ｐｒｏｖｉｄｅｄ

฀฀ ｳ฀฀Ｄａｔｅ฀ｅｘｐｅｎｓｅ฀ｗａｓ฀ｉｎｃｕｒｒｅｄ

฀฀ ｳ฀฀Ｐｅｒｓｏｎ฀ｏｒ฀ｏｒｇａｎｉｚａｔｉｏｎ฀ｐｒｏｖｉｄｉｎｇ฀ｔｈｅ฀ｓｅｒｖｉｃｅ฀ａｎｄ฀ｐｒｏｄｕｃｔ

฀฀ ｳ฀฀Ａｍｏｕｎｔ฀ｏｆ฀ｅｘｐｅｎｓｅ

OTC Medicine/Drugs. Please refer to the OTC Medicines Quick Reference Guide for details. – You must submit copies of the prescription, label of the box/container, as well as your receipt.

OTC Non-Medicine/Drugs – If your receipt does not clearly show the name of the product, you must submit copies of the label from the box/container.

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

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．฀

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

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

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

Ｐｌｅａｓｅ฀ｒｅｍｅｍｂｅｒ฀ｔｈａｔ฀ＦＳＡＦＥＤＳ฀ｈａｓ฀ａ฀ｍｉｎｉｍｕｍ฀ｒｅｉｍｂｕｒｓｅｍｅｎｔ฀ｔｈｒｅｓｈｏｌｄ฀ｏｆ฀$２５．００．฀Ｉｆ฀ｙｏｕｒ฀ｃｌａｉｍ฀ｄｏｅｓ฀ｎｏｔ฀ ｔｏｔａｌ฀$２５．００，฀ｉｔ฀ｗｉｌｌ฀ｂｅ฀ｐｒｏｃｅｓｓｅｄ฀ａｎｄ฀ｙｏｕ฀ｗｉｌｌ฀ｒｅｃｅｉｖｅ฀ａ฀ｒｅｉｍｂｕｒｓｅｍｅｎｔ฀ｓｔａｔｅｍｅｎｔ，฀ｂｕｔ฀ｙｏｕｒ฀ｐａｙｍｅｎｔ฀ｗｉｌｌ฀ｂｅ฀ ｐｅｎｄｅｄ฀ｕｎｔｉｌ฀ｙｏｕ฀ｓｕｂｍｉｔ฀ａｎｏｔｈｅｒ฀ｃｌａｉｍ฀ａｎｄ฀ｒｅａｃｈ฀ｔｈｅ฀$２５．００฀ａｇｇｒｅｇａｔｅ฀ａｍｏｕｎｔ，฀ｏｒ฀ｕｎｔｉｌ฀ｔｈｅ฀ｅｎｄ฀ｏｆ฀ｔｈｅ฀

quarter, whichever comes first.

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

Medical codes

Dental code

฀

１０２฀=฀ｏｖｅｒ－ｔｈｅ－ｃｏｕｎｔｅｒ฀ｎｏｎ－ｄｒｕｇｓ/ｍｅｄｉｃｉｎｅｓ฀

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

฀

１０３฀=฀ｐｒｅｓｃｒｉｐｔｉｏｎｓ฀ｏｒ฀ｐｒｅｓｃｒｉｐｔｉｏｎ฀ｃｏ－ｐａｙｓ

ｃｒｏｗｎｓ，฀ｉｍｐｌａｎｔｓ，฀ｄｅｎｔｕｒｅｓ฀－฀ｏｒ฀ｕｓｅ฀１０２฀ｏｒ฀

฀

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

１１７฀ｆｏｒ฀ｏｖｅｒ－ｔｈｅ－ｃｏｕｎｔｅｒ฀ｉｔｅｍｓ）

฀ ２０３฀=฀ｏｒｔｈｏｄｏｎｔｉａ

฀ １１７฀=฀ｏｖｅｒ－ｔｈｅ－ｃｏｕｎｔｅｒ฀ｄｒｕｇｓ/ｍｅｄｉｃｉｎｅｓ฀

 

 

(prescription required)

Vision code

฀

１２０฀=฀ｍｉｌｅａｇｅ

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

Other code

ｌｅｎｓｅｓ฀－฀ｏｒ฀ｕｓｅ฀１０２฀ｏｒ฀１１７฀ｆｏｒ฀ｏｖｅｒ－ｔｈｅ－ｃｏｕｎｔｅｒ฀

items)

฀฀฀฀฀999฀=฀ｏｔｈｅｒ

 

Type of Supporting Documentation:

ｳ฀Ｉｔｅｍｉｚｅｄ฀ｒｅｃｅｉｐｔ฀ｆｒｏｍ฀ｙｏｕｒ฀ｍｅｄｉｃａｌ，฀ｄｅｎｔａｌ฀

or vision provider or pharmacy

ｳ฀Ｅｘｐｌａｎａｔｉｏｎ฀ｏｆ฀Ｂｅｎｅｬｔｓ฀（ＥＯＢ）฀ｆｒｏｍ฀ｙｏｕｒ฀฀฀฀฀฀฀฀฀฀

insurance company or health care provider ｳ฀฀Ｐｒｅｓｃｒｉｐｔｉｏｎ฀ｗｒｉｔｔｅｎ฀ｂｙ฀ｙｏｕｒ฀ｈｅａｌｔｈｃａｒｅ฀

provider which must include:

-The date

-The name of the patient for whom the OTC item is prescribed

-The name of the OTC item (if you purchase a generic item, you must provide documentation that supports that it is the therapeutic equivalent to the prescribed drug)

-The dosage requirement (the potency of the item purchased must match the prescribed amount)

-The number of refills (unless it is a one-time purchase)

-The provider’s address and license number

Helpful Hints:

ｳ฀Add together similar expenses from the same Coverage Code and place that total on one

line (e.g., several over-the-counter items – Ｃｏｄｅ฀１０２，฀ｍｕｌｔｉｐｌｅ฀ｐｒｅｓｃｒｉｐｔｉｏｎ฀ｃｏｐａｙｓ฀– Ｃｏｄｅ฀１０３，฀ｅｔｃ．）．฀ＦＳＡＦＥＤＳ฀ｗｉｌｌ฀ｐｒｏｃｅｓｓ฀ｔｈｅｍ฀

separately and they will be reflected as separate amounts on your account.

ｳProvide the span of dates of service

（ｅ．ｇ．฀０１/０１/０８฀－฀０６/３０/０８）

ｳEnter the total amount on one line

ｳBe sure to include legible receipts for each expense included in the overall total

ｳ฀Ｂｅ฀ｓｕｒｅ฀ｔｏ฀ｕｓｅ฀ｙｏｕｒ฀ＦＳＡＦＥＤＳ฀ＵｓｅｒＩＤ ｳ฀Ｂｅ฀ｓｕｒｅ฀ｙｏｕｒ฀ｓｉｇｎａｔｕｒｅ฀ｉｓ฀ｌｅｇｉｂｌｅ

ｳ฀Ｂｅ฀ｓｕｒｅ฀ｃｏｐｉｅｓ฀ｏｆ฀ＯＴＣ฀ｌａｂｅｌｓ，฀ｉｆ฀ｒｅｑｕｉｒｅｄ，฀ａｒｅ฀

clear enough to fax

ｳ฀Ｔｈｅ฀Ｔｏｔａｌ฀Ｒｅｑｕｅｓｔｅｄ฀ｂｏｘ฀ｗｉｌｌ฀ａｕｔｏｍａｔｉｃａｌｌｙ฀

calculate the sum of expenses you list on page ２，฀ｏｒ฀ｐａｇｅｓ฀２฀ａｎｄ฀３．

Please Do NOT :

ｳ฀Ｅｍａｉｌ฀ｙｏｕｒ฀ｃｌａｉｍ฀ｆｏｒｍ ｳ฀Ｕｓｅ฀ｒｅｄ฀ｉｎｋ

ｳ฀Ｕｓｅ฀ａ฀ｐｈｏｔｏｃｏｐｙ฀ｏｆ฀ｔｈｉｓ฀ｆｏｒｍ

ｳ฀Ｕｓｅ฀ａ฀ｈｉｇｈｌｉｇｈｔｅｒ฀ｏｎ฀ｙｏｕｒ฀ｒｅｃｅｉｐｔｓ฀ｏｒ฀ａｎｙ฀

part of the form

ｳ฀Ｓｔａｐｌｅ฀ｙｏｕｒ฀ｃｏｐｉｅｄ฀ｒｅｃｅｉｐｔｓ฀ｔｏ฀ｔｈｅ฀ｆｏｒｍ ｳ฀Ｗｒｉｔｅ฀ｏｕｔｓｉｄｅ฀ｔｈｅ฀ｂｏｘｅｓ฀ｐｒｏｖｉｄｅｄ

ｳ฀Ｆａｘ฀ｔｈｅ฀ｓａｍｅ฀ｆｏｒｍ฀ｍｏｒｅ฀ｔｈａｎ฀ｏｎｃｅ

ｳ฀Ｍａｉｌ฀ｔｈｅ฀ｓａｍｅ฀ｆｏｒｍ฀ｔｈａｔ฀ｙｏｕ฀ｈａｖｅ฀ｆａｘｅｄ

ｳ฀Ｉｎｃｌｕｄｅ฀ｔｈｉｓ฀ｉｎｓｔｒｕｃｔｉｏｎ฀ｓｈｅｅｔ฀ｗｉｔｈ฀ｙｏｕｒ฀ｆａｘ฀

Please DO:

ｳ฀Circle applicable items on your receipts (just don’t use a highlighter)

ｳ฀Ｕｓｅ฀ａｓ฀ｍａｎｙ฀ｓｈｅｅｔｓ฀ｆｏｒ฀ａｄｄｉｔｉｏｎａｌ฀ｅｘｐｅｎｓｅｓ฀ａｓ฀

you need

ｳ฀Ｕｓｅ฀ｃｏｄｅ฀999฀ｆｏｒ฀ａｎｙ฀ｅｌｉｇｉｂｌｅ฀ｉｔｅｍ฀ｔｈａｔ฀ｉｓｎ＇ｔ฀ covered by one of the other Coverage Codes

Questions? Need a list of eligible expenses? Go to www.FSAFEDS.com or contact an FSAFEDS Benefits Counselor at 1-877-FSAFEDS.

Page 1 - HEALTH CARE CLAIM FORM

 

 

 

MAIL: FSAFEDS Program

 

 

 

 

HEALTH CARE CLAIM FORM

 

 

 

 

 

 

 

 

 

 

PO Box 36880

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ｕｓｅ฀ｏｎｌｙ฀ＣＡＰＩＴＡＬ฀ＬＥＴＴＥＲＳ

 

 

 

 

 

 

 

 

 

 

Louisville, KY 40233

 

 

 

 

WKBVDY

 

 

 

 

 

 

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

 

ＩＮＴＥＲＮＡＬ฀ＵＳＥ฀ＯＮＬＹ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FSAFEDS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ＥＭＰＬＯＹＥＥ฀ＬＡＳＴ฀ＮＡＭＥ

ＥＭＰＬＯＹＥＥ฀ＦＩＲＳＴ฀ＮＡＭＥ

 

ＥＭＰＬＯＹＥＥ฀ＥＭＡＩＬ

 

ＤＡＹＴＩＭＥ฀ＰＨＯＮＥ฀＃฀（ＡＲＥＡ฀ＣＯＤＥ฀ＦＩＲＳＴ，฀ＮＯ฀ＤＡＳＨＥＳ）

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2: YOUR HEALTH CARE EXPENSES

EXPENSE 1

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

 

 

 

 

ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVERAGE CODE (SEE PAGE 1)

ＴＯ฀฀（ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

EXPENSE 2

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

 

 

 

 

ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVERAGE CODE (SEE PAGE 1)

ＴＯ฀฀（ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

TOTAL REQUESTED (SUM OF EXPENSES FROM ALL PAGES SUBMITTED)

SECTION 3: CERTIFICATION Please read carefully before signing.

$

.

 

 

 

 

 

 

 

 

I affirm that:

ｳ฀฀฀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

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

I understand that:

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

ｳ฀฀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．฀฀

ｳ฀฀฀Ｉ ｈａｖｅ฀ｕｎｔｉｌ฀Ａｐｒｉｌ฀３０฀ｆｏｌｌｏｗｉｎｇ฀ｔｈｅ฀ｅｎｄ฀ｏｆ฀ｔｈｅ฀Ｂｅｎｅｬｔ฀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.

ｳ฀฀฀Ｉ ｃａｎｎｏｔ฀ｕｓｅ฀ｈｅａｌｔｈ฀ｃａｒｅ฀ｅｘｐｅｎｓｅｓ฀ｒｅｉｍｂｕｒｓｅｄ฀ｔｈｒｏｕｇｈ฀ｍｙ฀ｇｅｎｅｒａｌ฀ｐｕｒｐｏｓｅ฀ＨＣＦＳＡ฀ｏｒ฀ＬＥＸ฀ＨＣＦＳＡ฀ａｓ฀ａ฀ｄｅｄｕｃｔｉｏｎ฀ｏｎ฀ｍｙ฀ｐｅｒｓｏｎａｌ฀ｉｎｃｏｍｅ฀ｔａｘ฀ｒｅｔｕｒｎ． ｳ฀Ｔｈｅ฀ｅｘｐｅｎｓｅｓ฀ｆｏｒ฀ｗｈｉｃｈ฀Ｉ฀ａｍ฀ｒｅｑｕｅｓｔｉｎｇ฀ｒｅｉｍｂｕｒｓｅｍｅｎｔ฀ａｒｅ฀ｆｏｒ฀ｍｙｓｅｌｆ，฀ｍｙ฀ｓｐｏｕｓｅ，฀ｍｙ฀ｄｅｐｅｎｄｅｎｔ฀ｏｒ฀ａｄｕｌｔ฀ｃｈｉｌｄ฀ｔｈｒｏｕｇｈ฀ａｇｅ฀２６．

฀฀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）

Page 2 - HEALTH CARE CLAIM FORM

WKBVDY

COVERAGE CODE (SEE PAGE 1)
EXPENSE 4
COVERAGE CODE (SEE PAGE 1)
EXPENSE 5
COVERAGE CODE (SEE PAGE 1)
EXPENSE 6
COVERAGE CODE (SEE PAGE 1)
EXPENSE 7
COVERAGE CODE (SEE PAGE 1)
SECTION 4: EMPLOYEE INFORMATION (ABBREVIATED)
ＥＭＰＬＯＹＥＥ฀ＵＳＥＲ฀ＩＤ฀（ＮＯ฀ＤＡＳＨＥＳ）
ＥＭＰＬＯＹＥＥ฀ＬＡＳＴ฀ＮＡＭＥ
SECTION 5: YOUR ADDITIONAL HEALTH CARE EXPENSES
EXPENSE 3DATES OF SERVICE ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

USE THIS PAGE FOR ADDITIONAL HEALTH CARE EXPENSES.

HKLUMD

ＥＭＰＬＯＹＥＥ฀ＦＩＲＳＴ฀ＮＡＭＥ

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

$

 

 

 

 

.

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

 

 

 

 

TO （ＭＭＤＤＹＹ）

 

 

 

 

 

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO ฀（ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

ＦＲＯＭ฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO （ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO （ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

DATES OF SERVICE

ＡＭＯＵＮＴ฀ＲＥＱＵＥＳＴＥＤ฀（ＤＯＬＬＡＲＳ ． ＣＥＮＴＳ）

ＦＲＯＭ฀฀（ＭＭＤＤＹＹ）

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO （ＭＭＤＤＹＹ）

ＦＡＭＩＬＹ฀ＭＥＭＢＥＲ＇Ｓ฀ＮＡＭＥ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPORTING

ＤＯＣＵＭＥＮＴＡＴＩＯＮ฀ＡＴＴＡＣＨＥＤ？

YESNO

ＵＳＥ฀ＡＮ฀ＯＲＩＧＩＮＡＬ฀ＦＯＲＭ฀（ＮＯＴ฀Ａ฀ＰＨＯＴＯＣＯＰＹ）

Page 3 - HEALTH CARE CLAIM FORM

HKLUMD

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How you can fill in care claim stage 1

2. Soon after the previous part is filled out, go on to enter the suitable information in these: Ｕｓｅｃｏｄｅｆｏｒａｎｙｅｌｉｇｉｂｌｅｉｔｅｍｔｈａｔｉｓｎｔ, Questions Need a list of eligible, and Page HEALTH CARE CLAIM FORM.

Page HEALTH CARE CLAIM FORM, Questions Need a list of eligible, and Ｕｓｅｃｏｄｅｆｏｒａｎｙｅｌｉｇｉｂｌｅｉｔｅｍｔｈａｔｉｓｎｔ of care claim

3. The following segment should be fairly straightforward, FSAFEDS, SECTION YOUR HEALTH CARE EXPENSES, EXPENSE, DATES OF SERVICE ＦＲＯＭ ＭＭＤＤＹＹ, COVERAGE CODE, SEE PAGE, EXPENSE, DATES OF SERVICE ＦＲＯＭ ＭＭＤＤＹＹ, SUPPORTING, YES, and SUPPORTING - all of these form fields must be filled out here.

DATES OF SERVICE ＦＲＯＭ ＭＭＤＤＹＹ, SEE PAGE, and FSAFEDS inside care claim

4. Your next section requires your details in the following places: COVERAGE CODE, SEE PAGE, YES, SECTION CERTIFICATION Please read, TOTAL REQUESTED SUM OF EXPENSES, and I affirm that Ｉ. Make sure that you give all of the needed details to move onward.

Filling in part 4 in care claim

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Employee Signature Your signature, Page HEALTH CARE CLAIM FORM, and I affirm that Ｉ in care claim

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