Form Cl-472 - Request For Reimbursement Preferred Health Fsa/hra - Blue Cross Blue Shield Of Alabama

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REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA

Attach a copy of the itemized bill and an Explanation of Benefits (EOB) (if applicable) along with proof of

payment. All documentation must include the patient name, description of service provided, date provided, and

the charge. Be sure to sign and date this form before sending it with all attachments to the address shown.

An Independent Licensee of the Blue Cross and Blue Shield Association

I certify that the attached expenses are eligible for reimbursement from my designated Health FSA/HRA and that they qualify as deductions

Blue Cross and Blue Shield of Alabama

as outlined by the U. S. Internal Revenue Code or by my employer. I request reimbursement up to the limit allowed in my account. I further

Preferred Blue Accounts

certify that these expenses have not been reimbursed and are not reimbursable under any other benefit plan. A dependent must be

P.O. Box 11586

considered an eligible dependent under the applicable provisions of section 105 and 106 of the U.S. Internal Revenue Code.

Birmingham, Alabama 35202-1586

1-800-213-7930

Signature of Employee

Date

Toll Free Fax 1-877-889-3610

Visit our web site

for detailed account information

Important: This form is not used to reimburse you for your Blue Cross and Blue Shield of Alabama health benefits. It may only be used to request a payment from a tax-deferred, employee-funded spending account

established by your employer under Section 125 of the U.S. Internal Revenue Code or from your HRA established by your employer. Payments from such an account may only be made for qualified expenses on behalf of

qualified dependents when such expenses have not been reimbursed and are not reimbursable by any other benefit plan.

SECTION 1:

EMPLOYEE INFORMATION

FIRST NAME

LAST NAME

DATE OF BIRTH

PREFERRED BLUE ACCOUNT NUMBER

NOTE: Your Preferred Blue Account number is your Blue Cross and

Blue Shield of Alabama contract number. If you do not have

your account number, please contact Customer Service at

–

1-800-213-7930.

COMPANY NAME

WORK PHONE (Please include area code)

HOME PHONE (Please include area code)

SECTION 2:

HEALTH FSA/HRA REIMBURSEMENT INFORMATION

In order to be properly reimbursed, complete this section for each eligible expense and attach all necessary itemized receipts. (PLEASE DO NOT HIGHLIGHT ITEMS ON YOUR RECEIPTS.)

PATIENT’S FIRST NAME

LAST NAME

TYPE SERVICE

MEDICAL

VISION

AMOUNT

DENTAL

RELATIONSHIP

SELF

SPOUSE

DEPENDENT

COVERED BY INSURANCE