Flexible Spending Account Claim Form printable pdf download

Flexible Spending Account Claim Form

1 .Participant Information and Signature

Account(s) as listed below. I agree to the Terms and Conditions stated below; I certify and warrant that these are eligible Unreimbursed Medical

and/or Dependent Care expenses (see back) that my dependents or I have By submitting this claim form, I (participant named below) request

reimbursement from my Flexible Spending incurred.

Participant Name (please print): _________________________________________________________________________

Participant Address (complete only if address has changed):____________________________________________________

Kit Carson County

Employer Name______

_______________________________________________________________

How may we contact you during the day? E-Mail:_________________________________ Phone: ____________________

Participant Signature: ______________________________________________________ Date:_______________________

2. Unreimbursed Medical

Patient Name

Provider Name

Description of Service

Date Service

Requested Amount

Provided

3. Terms and Conditions

(above-named participant) understand and agree that:



These expenses are not reimbursable from any other health plan, insurance, or other source, and will not be used to claim any federal income tax deduction or

credit.



The Unreimbursed Medical expenses listed above would be deductible medical expenses under Internal Reven ue Code Section 213(d) and are allowed under

Prop. Treas. Reg1.125-2



The Dependent Care expenses listed above qualify for the federal child care credit, and I will not be eligible to claim the tax cr edit for any Dependent care

expenses submitted.



I will include the Taxpayer Identification/Social Security number(s) of any Dependent Care service provider(s) listed above on my annual tax return(s) using Form

2441.



I am responsible for any inappropriate use or disclosure of my information that occurs due to my selected method of transmitting this information (e.g, fax, e-

mail, or any other media).



I authorize the Plan and its service provider, their respective agents, employees, subcontractors, and assigns to use and/or disclose the information provided

above as they reasonably deem necessary to manage the Plan (including but not limited to, disclosures to my employer for Plan administration purposes, such

as the evaluation of eligibility for reimbursement under the Plan) and to detect or prevent fraud or misrepresentation.



I give up any claims related to the use, disclosure, or release of this information so long as the information is used for th e purposes defined above.



This authorization does not in any way limit any right for said insurer, respective agents, employees, subcontractors, and/or any assigns may have under

applicable state or federal law or regulation regarding the use of such information.

Flexible Spending Account Claim Form

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