Form Fsa003 - Reimbursement Claim - Flexible Spending Account (Paychex)
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1FOR OFFICE USE ONLY
Docket # __________________________
Reimbursement Claim
Flexible Spending Account
EMPLOYEE INFORMATION (print)
Office/Client Number
/
Employee Name ____________________________________________ Company Name ___________________________________
Social Security Number _______________________________________ Employee Phone Number (
)
REMINDERS:
MAIL TO:
•
Sign your claim form, and retain a copy for your records.
Paychex, Inc.
•
All claim reimbursements will be processed within 10 business days upon receipt of the completed
Section 125 Department
claim form and all supporting documentation.
FSA Claims
•
Enclose a copy of all itemized bills and/or receipts from your provider for reimbursement. Copies
1175 John Street
of personal checks and credit card receipts are not accepted as proof of payment.
•
West Henrietta, NY 14586
Verify that bills contain the date and description of service, the amount, and the provider’s name and
address on receipt. Dependent care bills must include the provider’s Federal ID or social security
Fax: 1-585-654-3205
number.
•
Claims must exceed $25.00 before reimbursement will be processed.
•
Enclose a copy of the orthodontist contract for first time orthodontia claims.
•
If you have a Flexible Spending Account in conjunction with a Health Savings Account (HSA), you
may only submit medical expenses under the Unreimbursed Medical portion of your Flexible
Spending Account for dental, vision, and preventative care. Your HSA may be used to pay for any
remaining HSA-qualified medical expenses.
If you have any questions, visit , phone the Paychex Flexible Spending Account Information Line at
1-888-712-0088, or contact the Client Service Center at 1-877-244-1771.
Claim Ref.
Member Name
Relationship
Date(s) Service
Description
Provider
Amount
to Employee*
Performed
of Service
of Service
01
02
03
04
05
06
07
08
09
10
* Self/Spouse/Child/Other (Specify)
TOTAL
CLAIM INFORMATION
I certify that the information here is true and correct, that the expenses incurred were for myself, spouse, or dependents, and that these
expenses are not reimbursable under any other health plan coverage.
Employee Signature _____________________________________________________
Date
/
/
FSA003 7/06
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