Flexible Spending Account Claim Form
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2FLEXIBLE SPENDING ACCOUNT CLAIM FORM
Employee Name _____________________________________________________ M# ___________________________________
Department ________________________
Phone __________________________Flexible Spending Calendar Year ____________
Use a separate claim form for each account
Select the type of claim by placing an “X” in the appropriate box
To qualify for reimbursement the expense must be incurred by you or one of your dependents who is claimed as a
dependent on your federal income tax return
Minimum request amount is $100.00 (Your final calendar-year claim may be less than $100.00)
Health Care Spending Account
Dependent Care Spending Account
The following items are required for reimbursement:
The following is required for reimbursement:
1) All medical, dental and optical claims must first be
1) A receipt from the provider of service must include
processed through your insurance plan before submitting
Provider name, address, contact information
to your health care reimbursement account.
Dependent name
2) All pages of the “Explanation of Benefits” (EOB) from your
Dates of service (begin and end)
Insurance plan must be attached to claim, if applicable.
Description of service
3) Attach the pharmacy receipt including the name of patient,
Expense amount
Date filled, and cost of prescription or you may include
Claim activity from your insurance plan.
4) Over the counter medications require a prescription from
2) Prepaid expenses cannot be reimbursed until the expense
a provider to be eligible for reimbursement.
has been incurred.
INCOMPLETE CLAIMS WILL BE RETURNED – ITEMIZE EACH DATE OF SERVICE – DO NOT COMBINE MULTIPLE CLAIMS IN ONE LINE
Family Member for Whom
Date of Service
Provider Name
Amount Claiming
Expense was Incurred
Month/Day/Year
Total Reimbursement Request Amount (Minimum $100)
I request reimbursement for the expenses itemized above. I certify I have not requested reimbursement under this plan or
from any other source for the above mentioned expenses. I also certify the total Dependent Care expenses for which I am
requesting reimbursement for this plan year do not exceed the lesser of my or my spouse’s expected income for the year. I
further certify the Health Care and Dependent Care expenses meet all the requirements listed on page two of this form.
Employee Signature _______________________________________________________ Date ___________________________
04/28/2015
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